Emily is a 75-year-old woman with congestive cardiac failure and chronic obstructive airways disease. Before she became ill and was admitted to hospital, her GP had changed her medications. Emily had been confused by the change, and had taken the wrong tablets at the wrong time in the wrong quantity. This had caused her to have too much carbon dioxide and not enough oxygen in her blood, as a result of which she developed myoclonic jerks. At the time she was admitted to hospital, Emily's family were told that she might not survive 48 hours.

Objective Limited health literacy and numeracy are associated with worse patient-reported outcomes and higher disease activity in systemic lupus erythematosus (SLE), but which factors may mediate this association is unknown. We sought to determine the association of health literacy and numeracy with lupus knowledge. Methods Patients with SLE were recruited from an academic center clinic. Participants completed validated assessments of health literacy (Newest Vital Sign, NVS) and numeracy (Numeracy Understanding in Medicine Instrument Shortened Version, S-NUMi) and answered four questions to assess lupus knowledge (Lupus Knowledge Assessment Test, LKAT) determined through consensus expert opinion of wide applicability and importance related to self-management. Descriptive statistics and multivariable logistic regression modeling were used to analyze results. Results In our lupus cohort (n=125), 33% had limited health literacy and 76% had limited numeracy. The majority correctly identified that hydroxychloroquine prevented lupus flares (91%); however, only 23% of participants correctly answered a numeracy question assessing which urine protein to creatinine (UPC) ratio was greater than 1000 mg/g. The mean LKAT score was 2.7 out of 4.0. Limited health literacy, but not numeracy, was associated with lower knowledge about SLE as measured by the LKAT, even after adjusting for education. Conclusion Patients with SLE with limited health literacy had lower knowledge about SLE. The LKAT could be further refined and/or used as a screening tool to identify patients with knowledge gaps. Further work is needed to improve understanding of proteinuria and investigate whether literacy-sensitive education can improve care.

A 42-year-old man living with HIV (viral load, 220 copies/mL; CD4 count, 408 cells/μL) presented with 2 days of confusion and vision changes. He also reported constant headache and dizziness but denied weakness, fevers, or chills. He was disoriented to time, had word-finding difficulties, poor concentration, and impaired short-term memory. Neurologic examination was notable for right homonymous hemianopia but no motor, sensory, or other cranial nerve abnormalities. Cerebrospinal fluid analysis showed

Objective Medication nonadherence is common among patients with systemic lupus erythematosus (SLE), and adherence often fluctuates with time. Underrepresented racial minorities have disproportionately lower rates of medication adherence and more severe SLE manifestations. We aimed to identify modifiable factors associated with persistent medication nonadherence. Methods Patients taking ≥1 SLE medication were enrolled. Adherence data were obtained at baseline and at follow‐up roughly 1 year later using both self‐reported adherence and pharmacy refill data. Covariates included patient–provider interaction, patient self‐efficacy, and clinical factors. We compared characteristics of patients in 3 groups using the Kruskal‐Wallis H test: persistent nonadherence (low adherence by self‐report and refill rates at both time points); persistent adherence (high adherence by self‐report and refill rates at both time points); and inconsistent adherence (the remainder). Results Among 77 patients (median age 44 years, 53% Black, 96% female), 48% had persistent nonadherence. Compared with other adherence groups, patients with persistent nonadherence were younger and more likely to be Black, have lower income, take ≥2 SLE medications, have higher SLE‐related damage at baseline, and have higher physician global assessment of disease activity at follow‐up. Persistently nonadherent patients also rated more hurried communication with providers (particularly fast speech and difficult word choice) and had lower self‐efficacy in managing medications. Conclusion Potential avenues to improve medication adherence include optimizing patient–provider communication, specifically avoiding difficult vocabulary and fast speech, and enhancing patient self‐efficacy, particularly among younger Black patients with lower income who are at higher risk for nonadherence.

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