Getting to the Heart of the Matter: A Case of Seronegative Antiphospholipid Syndrome

Case Presentation: A 52-year-old gentleman with past medical history of lupus nephritis, non-ST-elevation myocardial infarction, venous thromboembolism (on anticoagulation), and peripheral vascular disease requiring arterial bypass grafting presented to the hospital with two days of left toe pain, fever and chills. Physical exam demonstrated gangrenous changes of the left second toe as well as nontender, nonblanching erythematous macules along the plantar surface of the foot. Laboratory evaluation revealed prolonged partial thromboplastin time and elevated inflammatory markers without leukocytosis. Infectious serologies and final blood cultures were negative. Hypercoagulability studies, including antiphospholipid antibody titers and lupus anticoagulant, were normal. On imaging, he was found to have a patent bypass graft but was noted to have a 2.5-cm vegetation on the tricuspid valve. He had no atrial septal defect. Intravenous antibiotics were initiated for 4 weeks without resolution, and the patient underwent surgical tricuspid valve replacement and toe amputation. Intraoperative pathology was notable for sterile vegetation and toes with arterial thrombus but no vasculitis nor organisms on Gram stain or final culture. Discussion: Antiphospholipid syndrome (APS) is a hypercoagulable state which often occurs secondary to systemic lupus erythematosus (SLE). The diagnostic criteria for APS require the presence of at least one clinical and one laboratory criterion. Clinical criteria include vascular thrombosis or pregnancy morbidity and laboratory criteria include the presence of lupus anticoagulant, anti-cardiolipin, or anti-β2-glycoprotein. APS also predisposes to the development of sterile thrombotic Libman-Sacks endocarditis, which most commonly affects the mitral valve. Seronegative APS (SN-APS) is diagnosed when clinical criteria are met but serologic testing is negative. Testing must be performed outside the contexts of acute thrombosis and treatment with anticoagulation, as these conditions can cause a transient loss or consumption of antiphospholipid antibodies. This patient\u27s case was unusual for several reasons. His Libman-Sacks endocarditis was located on the tricuspid valve, a rare presentation. Moreover, his toe ischemia was the result of an arterial thrombus rather than embolism or ischemia from graft stenosis. Given his extensive history of hypercoagulability in the setting of known SLE, thrombosis secondary to SN-APS was the unifying diagnosis. Conclusions: APS is a hypercoagulable state associated with SLE. It confers increased risk of developing Libman-Sacks endocarditis as well as peripheral thrombotic events which may mimic other clinical entities such as limb ischemia or embolism. It is a clinically important diagnosis to consider in patients with clinical manifestations of the syndrome but persistently negative serology

70 Years of Progress: History of the D.C. Rheumatism Society, 1946-2016

In the aftermath of the Second World War, medical practice was at a turning point. Antibiotic therapy with penicillin and anti-inflammatory therapy with aspirin had just reached mainstream use. The National Institutes of Health had just been established, creating a place for young investigators to discover novel solutions to intractable problems in medicine. Multiple national societies appeared for the benefit of countless diseases, encouraging innovation and discovery. In the midst of this national engagement, a local special interest group, the Rheumatism Society of the District of Columbia (D.C. Rheum or the Society), became one of the first local rheumatological professional society. Founded in 1946, the Society aimed “to stimulate interest in and increase the knowledge of rheumatic diseases among physicians and laymen.” Originally a collection of physicians from various fields of medicine (including cardiology, pediatrics, and orthopedic surgery), D.C. Rheum grew to be a meeting place for the capital’s foremost intellectual contributors to the state of the art in the developing specialty of rheumatology. This paper uses primary sources gathered from PubMed, family archives, and the Society’s archive of meeting minutes in order to characterize the historical contribution and development of D.C. Rheum. In addition to describing how the Society evolved over time, this study contextualizes the activities of D.C. Rheum in the overall milieu of the science of rheumatology and aims to create a sense of the ways in which local professional societies interact with rapidly evolving scientific progress

Renal injury in scleromyxoedema due to monoclonal gammopathy associated C3 glomerulonephritis

Scleromyxoedema is a rare mucinosis that primarily affects the skin. It is associated with monoclonal gammopathy and has many extracutaneous manifestations, however, renal involvement is rare. We report the case of a woman with monoclonal gammopathy and scleromyxoedema presenting with progressive exertional dyspnoea and acute renal failure. Workup of her renal failure revealed monoclonal gammopathy associated C3 glomerulonephritis. She was treated with intravenous steroids and discharged with plans to pursue annual monoclonal gammopathy laboratory monitoring. Given the rarity of renal scleromyxoedema, careful investigation of extracutaneous manifestations and comorbidities is critical to discern the primary pathological process in patients with scleromyxoedema who develop renal insufficiency

Impact of a Student-Led Rheumatology Interest Group on Medical Student Interest in Rheumatology.

Objectives: This observational study was designed to evaluate the impact of a student-led Rheumatology Interest Group on medical student interest in rheumatology. Methods: The mean numbers of student-rheumatology interactions per six months were assessed for elective enrollment, abstract submissions, and manuscripts, in the pre- and postinterest group period. Results: Enrollment in the rheumatology elective increased from 2.0 ± 0.36 per six months in the preintervention period to 6.2 ± 1.24 per six months in the postintervention period (p=0.0064). Abstract submissions increased from 0.5 ± 0.34 to 5.86 ± 1.49 (p=0.0077), and manuscript submissions from 0.16 ± 0.16 to 1.57 ± 0.37 (p=0.074). Conclusion: The Rheumatology Interest Group significantly increased medical student engagement in rheumatology

Impact of a Student-Led Rheumatology Interest Group on Medical Student Interest in Rheumatology

Objectives. This observational study was designed to evaluate the impact of a student-led Rheumatology Interest Group on medical student interest in rheumatology. Methods. The mean numbers of student-rheumatology interactions per six months were assessed for elective enrollment, abstract submissions, and manuscripts, in the pre- and postinterest group period. Results. Enrollment in the rheumatology elective increased from 2.0 ± 0.36 per six months in the preintervention period to 6.2 ± 1.24 per six months in the postintervention period (p=0.0064). Abstract submissions increased from 0.5 ± 0.34 to 5.86 ± 1.49 (p=0.0077), and manuscript submissions from 0.16 ± 0.16 to 1.57 ± 0.37 (p=0.074). Conclusion. The Rheumatology Interest Group significantly increased medical student engagement in rheumatology

Improving the One Call Inter-Hospital Transfer System to Improve Patient Safety and Efficiency of Care

Introduction: As a tertiary care health center, George Washington University Hospital accepts transfers of care from regional hospitals for patients who need a higher level of care. Due to the high level of care that these patients require, they are often at increased risk of bad outcomes or even death due to their clinical state. However, since these patients are admitted directly to GW Hospital under inpatient status, they bypass the well-developed triaging systems that are in place in the emergency department. Given the relatively high proportion of patient safety concerns surrounding this admission system, a project was undertaken with a goal of expediting time-to-evaluation by the general medicine admitting physician teams. Methods: Key stakeholders around the One-Call Hospital transfer system were engaged, including the internal medicine medical residents, nurses, charge nurses, nursing administration, and bedboard. A first PDSA cycle was attempted with the goal of creating an order-set protocol to be executed by floor nurses. This PDSA was unsuccessful and attributed to difficulty identifying individuals who could easily lead such changes as well as concerns about educating all floor nurses about this potential process change. A second PDSA cycle was attempted in which BedBoard associates were given a TigerText account and instructed to text the Medicine Admitting On-Call Officer once patients arrived by ambulance (in contrast to the original system of having the floor nurse call the admitting team once the patient had been situated floor). During the PDSA cycle, the original system of having floor nurses notify the admitting teams was kept in place. The primary outcome will be the difference in time from arrival at GW Hospital to the time of initial admission order placed by the internal medicine admitting teams by review of the electronic medical record. Results: Final data on this PDSA cycle will be available by March 2018. Preliminary verbal reports from admitting residents physicians suggests that they have received notifications from BedBoard about the arrival of transfer patients an estimated 30 minutes before receiving notifications from floor nurses in some instances. Admitting resident physicians had a highly positive subjective view of this process change. Conclusions: Preliminary evidence suggests that the second PDSA is successful and will facilitate earlier evaluations of transferred patients by internal medicine resident teams. Since these patients occasionally arrive from their transferring facilities with poor or deteriorating clinical conditions, this apparent decrease in time-to-evaluation is viewed as a tremendous success. Exploration of expanding this process to other departments may be warranted