Faculty Bibliography

Background: The recent prospectively validated definition of the lupus low disease activity state (LLDAS) allows characterisation of patients not achieving a treatment goal, providing impetus for an analysis of unmet needs in SLE using formal definitions. Other recently described definitions of high disease burden include disease activity over time, high disease activity status (HDAS) episodes, and the combination of high disease activity, serological activity and glucocorticoid (GC) use (HDAS+SA+GC).
Objective(s): To determine the prevalence of formal categories of unmet need, and the association of these with adverse outcomes, in SLE.
Method(s): Data from a 13-country longitudinal SLE cohort (ACR/SLICC criteria) were collected between 2013 and 19 using standard templates. Unmet need was defined as (i) patients never attaining LLDAS defined as in Golder et al., 2019 [1], (ii) having persistently active disease (time adjusted mean SLEDAI-2K (AMS) > 4), (iii) ever exhibiting high disease activity status (HDAS; SLEDAI-2K >=10[2]), or (iv) ever exhibiting all of SLEDAI>=10, serological activity, and glucocorticoid use (HDAS+SA+GC)[3]. Health-related quality of life (HRQoL) was assessed using SF36 (v2) surveys and damage accrual using SLE Damage Index (SDI).
Result(s): 3,384 SLE patients were followed for 30,313 visits over median [IQR] 2.4 [0.4, 4.3] years. 53% of all visits were not in LLDAS; 813 patients (24%) never achieved LLDAS during observation. Median AMS was 3.0 [1.4, 4.9] and 34% of patients had AMS > 4 throughout the study. 25% of patients had at least one episode of HDAS, representing 8% of visits. 702 patients (21%) had at least one episode of HDAS+SA+GC, representing 8% of visits. Each of never-LLDAS, AMS>4, ever-HDAS, and ever-HDAS+SA+GC were associated with significantly greater number of physician visits, higher mean glucocorticoid dose, lower HRQoL and higher mortality. 31%, 58% and 83% of never-LLDAS, AMS>4, and ever-HDAS patients respectively were also HDAS+SA+GC on at least one occasion.
Conclusion(s): Data from a multinational longitudinal SLE cohort indicate that unmet need, defined by LLDAS-never, AMS>4, HDAS, or HDAS+SA+GC, is prevalent in SLE, and that these definitions are associated with poor outcomes

Background and Objectives: This ACGME milestone-based pilot study investigated a social media based curriculum implemented to ease the transition of EM "pre-interns" to residency and found improvement in pre-intern perceived preparedness (PP) and clinical knowledge (CK). There has been no large-scale investigation of such a curriculum, and no standardized assessment of PP for residency. EM Milestones were used to create and implement our Slack Intern Curriculum (SIC) of clinical cases administered via social media. The hypothesis was that the SIC would increase pre-intern CK and PP for residency regarding levels 1 and 2 of selected Milestones Methods: Pre-interns were recruited among 11 EM residency programs in the Northeast USA. SIC was implemented March-July 2019. Subjects completed pre-, post-curriculum surveys assessing PP and CK on levels I, II of Milestones 1, 3, 4, 5, 7, 9, 10, and 12. Mann-Whitney U tests compared pre- and post-SIC Likert scale (1-5) response distributions for PP. Unpaired t-tests compared exam scores between pre- and post-SIC groups; subgroup scores evaluated performance within Milestones Results: 151 pre-interns were invited to participate. For PP, 127 and 85 participants completed the pre- and post-curriculum surveys, respectively. For CK, 115 and 63 participants completed the pre- and post-curriculum surveys. Increases in PP were found for Milestones 5, 9, 10, and 12, including ultrasound image optimization (pretest median: 2, posttest median: 3, U=6418, p=0.016), confirming ETT placement (pretest median: 3, posttest median: 4, U=6607.5, p=0.0041), RSI medication pharmacology (pretest median: 2, posttest median: 3, U=6654.5, p=0.0028), and outlining clinical procedure steps (pretest median: 2, posttest median: 3, U=6294.5, p=0.0326). There was no difference in mean exam scores after the curriculum, but Milestone 10 CK improved
Conclusion(s): SIC improved pre-intern PP for several Milestones, and CK for Milestone 10. Implementing SIC may ease transitions to residency. Knowledge of pre-intern PP will help residency leadership to better serve pre-interns. Limitations include variable participation and 45.2% lost-to-followup rate. Further studies will evaluate the correlation between trends in PP and CK before and after the SIC implementation

BACKGROUND: Iodine 123 metaiodobenzylguanidine (MIBG) imaging and heart rate variability (HRV) analysis were compared in patients with an implantable cardioverter defibrillator (ICD) who did and did not receive defibrillator discharges. Although the ICD has been shown to abort potentially fatal ventricular arrhythmias, identification of patients who most benefit from this device remains difficult. As the autonomic nervous system has been implicated in the genesis of these arrhythmias, we undertook a pilot study to evaluate local myocardial sympathetic innervation with the use of I-123 MIBG myocardial imaging, as well as central autonomic tone with the use of HRV, in patients with implantable defibrillators. Test results were correlated with the occurrence of ICD discharges. METHODS AND RESULTS: Seventeen patients with previously implanted defibrillators were studied. Of these, 10 had at least 1 appropriate device discharge for ventricular tachyarrhythmias, whereas 7 had no discharge. Patients with a discharge had a significantly lower I-123 MIBG heart-mediastinal tracer uptake ratio, higher I-123 MIBG defect scores, more extensive sympathetic denervation, and significantly reduced values for several HRV parameters, particularly those in the frequency domain. When combined, the I-123 MIBG heart-mediastinal ratio and HRV 5-minute low-frequency variables were highly predictive of defibrillator discharges. All patients with a heart-mediastinal ratio lower than 1.54 and 5-minute low frequency lower than 443 ms(2) had an ICD discharge (4/4), whereas no patient with an uptake ratio greater than 1.54 and 5-minute low frequency greater than 443 ms(2) did (0/3, P =.03). CONCLUSIONS: Cardiac autonomic assessment using a combination of myocardial scintigraphic and neurophysiologic techniques may help select patients who would most benefit from an implantable defibrillator by identifying those at increased risk for potentially fatal arrhythmias.