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The Lupus Foundation of America (LFA) convened an international working group to obtain a consensus definition of disease flare in lupus. With help from the Paediatric Rheumatology International Trials Organization (PRINTO), two web-based Delphi surveys of physicians were conducted. Subsequently, the LFA held a second consensus conference followed by a third Delphi survey to reach a community-wide agreement for flare definition. Sixty-nine of the 120 (57.5%) polled physicians responded to the first survey. Fifty-nine of the responses were available to draft 12 preliminary statements, which were circulated in the second survey. Eighty-seven of 118 (74%) physicians completed the second survey, with an agreement of 70% for 9/12 (75%) statements. During the second conference, three alternative flare definitions were consolidated and sent back to the international community. One hundred and sixteen of 146 (79.5%) responded, with agreement by 71/116 (61%) for the following definition: “A flare is a measurable increase in disease activity in one or more organ systems involving new or worse clinical signs and symptoms and/or laboratory measurements. It must be considered clinically significant by the assessor and usually there would be at least consideration of a change or an increase in treatment.” The LFA proposes this definition for lupus flare on the basis of its high face validity.

Treatment decision-making regarding immunosuppressive therapy is challenging for individuals with lupus. We assessed the effectiveness of a decision aid for immunosuppressive therapy in lupus nephritis. In a United States multicenter, open-label, randomized controlled trial (RCT), adult women with lupus nephritis, mostly from racial/ethnic minority backgrounds with low socioeconomic status (SES), seen in in- or outpatient settings, were randomized to an individualized, culturally tailored, computerized decision aid versus American College of Rheumatology (ACR) lupus pamphlet (1:1 ratio), using computer-generated randomization. We hypothesized that the co-primary outcomes of decisional conflict and informed choice regarding immunosuppressive medications would improve more in the decision aid group. Of 301 randomized women, 298 were analyzed; 47% were African-American, 26% Hispanic, and 15% white. Mean age (standard deviation [SD]) was 37 (12) years, 57% had annual income of <$40,000, and 36% had a high school education or less. Compared with the provision of the ACR lupus pamphlet (n = 147), participants randomized to the decision aid (n = 151) had (1) a clinically meaningful and statistically significant reduction in decisional conflict, 21.8 (standard error [SE], 2.5) versus 12.7 (SE, 2.0; p = 0.005) and (2) no difference in informed choice in the main analysis, 41% versus 31% (p = 0.08), but clinically meaningful and statistically significant difference in sensitivity analysis (net values for immunosuppressives positive [in favor] versus negative [against]), 50% versus 35% (p = 0.006). Unresolved decisional conflict was lower in the decision aid versus pamphlet groups, 22% versus 44% (p < 0.001). Significantly more patients in the decision aid versus pamphlet group rated information to be excellent for understanding lupus nephritis (49% versus 33%), risk factors (43% versus 27%), medication options (50% versus 33%; p ≤ 0.003 for all); and the ease of use of materials was higher in the decision aid versus pamphlet groups (51% versus 38%; p = 0.006). Key study limitations were the exclusion of men, short follow-up, and the lack of clinical outcomes, including medication adherence. An individualized decision aid was more effective than usual care in reducing decisional conflict for choice of immunosuppressive medications in women with lupus nephritis. Clinicaltrials.gov, NCT02319525.

Combined smoking and heavy drinking is a significant health burden. Varenicline, an efficacious tobacco pharmacotherapy that also shows promise for drinking, has yielded mixed results among heavy-drinking smokers. This pilot study investigated integrated tobacco and alcohol counselling plus varenicline for this vulnerable group. Twelve-week parallel, randomized controlled pilot trial of two behavioural interventions in combination with open-label varenicline. Participants were randomized using computer-generated tables, stratified by sex. Outpatient academic medical centre research clinic. Volunteers who reported smoking and heavy drinking and sought tobacco or alcohol treatment ( = 26). Intervention. (1) Integrated tobacco + alcohol counselling (INT; = 13) or (2) counselling focused on their presenting concern (i.e., tobacco or alcohol) (SINGLE; = 13), plus varenicline (2 mg) for 12 weeks. Feasibility/acceptability, smoking quit rates and heavy drinking. INT feasibility/acceptability was high among men but not women. More participants quit smoking in INT than SINGLE. This outcome was only in men, not significant, but had a medium effect size. Both conditions yielded significant drinking reductions. Integrated tobacco and alcohol behavioural counselling plus varenicline may be feasible and promote smoking cessation among men who smoke and drink heavily, but a larger sample is needed to replicate this finding.

Opioid-involved overdose deaths are on the rise, both nationwide and in the state of Washington. In a survey of 443 participants at syringe exchanges in Seattle, Washington, 16% had overdosed in the last year. Several factors were significantly associated in bivariate analysis: lack of permanent housing; incarceration of five or more days in the past year; gender of sex partners; sharing of syringes and other injection paraphernalia; use of speedballs (cocaine and heroin together), goofballs (methamphetamine and heroin together), buprenorphine; injection use of crack cocaine and sedatives; and use of opioids with sedatives. Adjusting for other variables in multivariate logistic regression analyses, only recent incarceration and sharing of injection materials were still significantly associated with overdose. Correctional facilities, syringe exchange programs, and other agencies serving opioid injectors should include overdose prevention components in release planning and services.

Background Emergency medicine is a highly interdisciplinary field, and emergency nurses and physicians have high rates of burnout compared to other specialties. National and international agencies prioritize investments in systems-based solutions to improve clinicians’ work environments. The objective of this study was to determine whether emergency department (ED) clinicians agree on the quality of work environments, and whether their agreement is associated with job outcomes, patient safety, and quality of care. Methods This cross-sectional study used data from 1,604 ED nurses ( n  = 1,190) and physicians ( n  = 414) who completed the 2021 US Clinician Wellbeing Study in 47 Magnet hospitals. A K-means algorithm classified hospitals into ‘profiles’ based on nurse and physician agreement on work environment assessments. Hospital-level linear regression models determined the relationship between hospital profiles and clinician job and patient outcomes. Results The overall clinician sample ( n  = 1,604) was on average 39.4 years of age (SD = 11.2), 72.3% female, with 8.3 years of experience (SD = 7.9), 77.7% White, and 93.6% non-Hispanic. Two hospital profiles indicated clinician agreement: “Agree, Unfavorable Environment” ( n  = 10 hospitals), and “Agree, Favorable Environment” ( n  = 15); the third profile indicated disagreement: “Disagree, Less Favorable Environment among Nurses” ( n  = 22). There were no hospital profiles with physicians rating their work environment less favorably than nurses. Compared to the “Agree, Favorable Environment” hospitals, the “Agree, Unfavorable Environment” and “Disagree, Less Favorable among Nurses” hospitals were associated with higher burnout (e.g., β = 25.8%, 95% CI 11.6, 40.1, p  <.001 and β = 15.4, 95% CI 3.7, 27.2, p  <.001, respectively), job dissatisfaction, and intent to leave; and unfavorable patient care quality and unfavorable patient safety grades (e.g., β = 29.1%, 95% CI 18.4, 39.8, p  <.001 and β = 11.9%, 95% CI 3.0, 20.8, p  <.01, respectively). Conclusions In this cross-sectional study, emergency nurses and physicians in almost half of study hospitals disagreed on the quality of the work environment, suggesting that two essential collaborators in high-stakes care do not agree on deficiencies in ED work environments. Sustainable systems-based solutions to improve ED work environments involve bridging these disparate workplace experiences.