The effect of smoking on cumulative damage in systemic lupus erythematosus: An incident cohort study.

OBJECTIVES: To investigate the relationship between smoking history and pack-year exposure on the rate of end-organ damage in systemic lupus erythematosus (SLE). METHODS: The SLE incident cohort included patients who met American College of Rheumatology (ACR) 1997 or SLE International Collaborating Clinics (SLICC) 2012 SLE criteria and had rheumatology encounters at a US academic institution (2008-16). The primary outcome was median time to SLICC/ACR damage index (SLICC/ACR-DI) increase or death. Main explanatory variables were smoking status and pack-years. Covariates included age, sex, race, ethnicity, receipt of Medicaid, neighborhood area deprivation index, and baseline SLE damage. Damage increase-free survival was evaluated by smoking status and pack-years using Kaplan-Meier and Cox proportional hazards methods. RESULTS: Patients of Black race and Medicaid recipients were more commonly current smokers (p's < 0.05). Former smokers were older and more likely to have late-onset SLE (54% versus 33% of never and 29% of current smokers, p = 0.001). Median time to SLICC/ACR-DI increase or death was earlier in current or former compared to never smokers (4.5 and 3.4 versus 9.0 yrs; p = 0.002). In multivariable models, the rate of damage accumulation was twice as fast in current smokers (HR 2.18; 1.33, 3.57) and smokers with a >10 pack-year history (HR 2.35; 1.15, 3.64) versus never smokers. CONCLUSIONS: In this incident SLE cohort, past or current smoking predicted new SLE damage 4-5 years earlier. After adjustment, current smokers and patients with a pack-year history of >10 years accumulated damage at twice the rate of never smokers.

Clinical Significance of Monitoring Hydroxychloroquine Levels in Patients With Systemic Lupus Erythematosus: A Systematic Review and Meta-Analysis.

OBJECTIVE: Despite the pivotal role that hydroxychloroquine (HCQ) plays in treating systemic lupus erythematosus (SLE), less than 50% of patients take HCQ as prescribed. Measurement of HCQ blood levels can help clinicians distinguish nonadherence versus lack of efficacy of HCQ. Our objective was to systematically review publications and perform a meta-analysis to examine the correlation between HCQ levels and 1) nonadherence and 2) Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores, in SLE. METHODS: A comprehensive search was performed. We included observational and interventional studies that measured HCQ levels and assessed adherence or SLEDAI scores in adults with SLE. Forest plots compared pooled estimates of correlations between HCQ levels and reported nonadherence or SLEDAI scores. RESULTS: Among 604 studies screened, 17 were reviewed. We found 3-times higher odds of reported nonadherence in patients with low HCQ levels (odds ratio 2.95 [95% confidence interval (95% CI) 1.63, 5.35], P < 0.001). The mean SLEDAI score was 3.14 points higher in groups with below-threshold HCQ levels on a priori analysis (δ = 3.14 [95% CI -0.05, 6.23], P = 0.053), and 1.4 points higher in groups with HCQ levels of <500 ng/ml (δ = 1.42 [95% CI 0.07, 2.76], P = 0.039). Among 1,223 patients, those with HCQ levels ≥750 ng/ml had a 58% lower risk of active disease, and their SLEDAI score was 3.2 points lower. CONCLUSION: We found a strong association between low HCQ levels and reported nonadherence. Our results suggest that HCQ levels of ≥750 ng/ml might be a potential therapeutic target.

Assessing Brief Changes in Adolescents' Mood: Development, Validation, and Utility of the Fast Assessment of Children's Emotions (FACE).

Mood states of youth have a strong influence on their cooperation, comfort, and engagement in many health care and educational settings. Children who are fearful, angry, or sad are more likely to have difficulty learning new skills or connecting with others. Many interventions are used in hospital and school settings to help youth, but it is difficult to assess their effectiveness without appropriate assessment tools that are easy to administer, age appropriate, and psychometrically sound. We examined the validity and reliability of the Fast Assessment of Children's Emotions (FACE). After obtaining parental consent and youth assent, 61 patients ages 12 to 17 years were recruited from the psychiatry services at a large children's hospital. Participants completed the FACE, the Brunel Mood Scale (BRUMS), and a measure of satiety at three time points-before and after a 60-minute psychotherapeutic intervention and after lunch. The FACE measure was significantly correlated with the BRUMS (r(2) = 0.85; p < .001) and not correlated with the satiety measure (r(2) = -0.17; not significant). Cronbach's α for the FACE was 0.7734. The FACE showed significant changes in mood from before to after the therapeutic intervention for all patients. For general psychiatry patients, the FACE did not change significantly after lunch, although for patients with eating disorders, the FACE did indicate an increase in distressed emotions after lunch. This finding indicates sensitivity to change in a clinically meaningful manner. The FACE is easy to use and may be used quickly to assess mood changes in adolescents.