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1.
Arthritis Rheumatol ; 72(4): 529-556, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32090480

RESUMO

OBJECTIVE: To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD). METHODS: We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary. RESULTS: This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD. CONCLUSION: This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.

2.
Arthritis Care Res (Hoboken) ; 72(4): 461-488, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32090466

RESUMO

OBJECTIVE: To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD). METHODS: We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary. RESULTS: This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD. CONCLUSION: This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.

3.
MMWR Morb Mortal Wkly Rep ; 68(38): 819-824, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31557148

RESUMO

Rheumatic diseases are a leading cause of chronic, noncancer pain. Systemic lupus erythematosus (SLE) is a chronic autoimmune rheumatic disease characterized by periodic flares that can result in irreversible target organ damage, including end-stage renal disease. Both intermittent and chronic musculoskeletal pain, as well as fibromyalgia (considered a centralized pain disorder due to dysregulation of pain processing in the central nervous system), are common in SLE. Opioids are generally not indicated for long-term management of musculoskeletal pain or centralized pain (fibromyalgia) because of lack of efficacy, safety issues ranging from adverse medical effects to overdose, and risk for addiction (1,2). In this study of 462 patients with SLE from the population-based Michigan Lupus Epidemiology and Surveillance (MILES) Cohort and 192 frequency-matched persons without SLE, nearly one third (31%) of SLE patients were using prescription opioids during the study period (2014-2015), compared with 8% of persons without SLE (p<0.001). Among the SLE patients using opioids, 97 (68%) were using them for >1 year, and 31 (22%) were concomitantly on two or more opioid medications. Among SLE patients, those using the emergency department (ED) were approximately twice as likely to use prescription opioids (odds ratio [OR] = 2.1; 95% confidence interval [CI] = 1.3-3.6; p = 0.004). In SLE, the combined contributions of underlying disease and adverse effects of immunosuppressive and glucocorticoid therapies already put patients at higher risk for some known adverse effects attributed to long-term opioid use. Addressing the widespread and long-term use of opioid therapy in SLE will require strategies aimed at preventing opioid initiation, tapering and discontinuation of opioids among patients who are not achieving treatment goals of reduced pain and increased function, and consideration of nonopioid pain management strategies.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Vigilância da População , Adulto , Idoso , Estudos de Coortes , Serviço Hospitalar de Emergência , Feminino , Humanos , Lúpus Eritematoso Sistêmico/epidemiologia , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Manejo da Dor/métodos , Risco
4.
Artigo em Inglês | MEDLINE | ID: mdl-31074595

RESUMO

OBJECTIVE: To examine associations between dietary intake of omega-3 (n-3; generally anti-inflammatory) and omega-6 (n-6; generally pro-inflammatory) fatty acids and patient-reported outcomes in systemic lupus erythematosus (SLE). METHODS: This study was based on the population-based Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. Estimates of n-3 and n-6 intake were derived from Diet History Questionnaire II items (DHQ II; past year with portion size version). Patient-reported outcomes included self-reported lupus activity (Systemic Lupus Activity Questionnaire/SLAQ). Multivariable regression, adjusted for age, sex, race, and body mass index, was used to assess associations between absolute intake of n-3 and n-6, as well as the n-6:n-3 ratio, and patient-reported outcomes. RESULTS: Among 456 SLE cases, 425 (93.2%) were female, 207 (45.4%) were black, and mean age was 52.9±12.3 years. Controlling for potential confounders, the average SLAQ score was significantly higher by 0.3 points [(95% CI 0.1, 0.6); p=0.013] with each unit increase of the n-6:n-3 ratio. Both lupus activity and PROMIS-Sleep Disturbance scores were lower with each 1g/1000 Kcal increase of n-3 fatty acids [SLAQ regression coefficient ß=-0.8 (95% CI -1.6, 0.0), p=0.055; PROMIS-Sleep ß=-1.1 (95% CI -2.0, -0.2), p=0.017]. Higher n-3 intakes were non-significantly associated with lower levels of depressive symptoms and comorbid fibromyalgia, and higher quality of life, whereas results for the n6:n3 ratio trended in the opposite direction. CONCLUSION: This population-based study suggests that higher dietary intake of n-3 fatty acids, and lower n-6:n-3 ratios, are favorably associated with patient-reported outcomes in SLE, particularly self-reported lupus activity and sleep quality. This article is protected by copyright. All rights reserved.

5.
Artigo em Inglês | MEDLINE | ID: mdl-32173263

RESUMO

Autoimmune diseases (AID) are more prevalent in women than in men, and pregnancy-related factors such as hormonal modulation and fetal microchimerism may influence the future risk of maternal AID. For women with AID, optimizing reproductive health requires a continuum of multidisciplinary care that initiates well before the desire for pregnancy is articulated. Family planning is essential so that pregnancy can be timed when disease is stable and to allow for appropriate medication adjustments. When contraception is used, the choice of method needs to take into consideration underlying disease and laboratory features. For females undergoing gonadotoxic therapy, options for preserving ovarian health and fertility warrant consideration, even among those who are not contemplating future pregnancy. Both maternal and fetal outcomes are optimized with multispecialty care as well as close monitoring during pregnancy and the postpartum period and when treatment regimens compatible with pregnancy are maintained to control underlying disease activity.

6.
Rheum Dis Clin North Am ; 43(2): 275-285, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28390569

RESUMO

Infertility and subfertility, menstrual irregularities, and decreased parity may occur in women with autoimmune diseases due to multiple factors, including underlying inflammatory disease, gonadotoxic medications, and psychosocial issues related to living with chronic disease. Awareness of these factors, as well as validation and support of patients confronting reproductive challenges, is important for providing comprehensive care to these women. An understanding of the expanding options for fertility preservation strategies during gonadotoxic medications is essential. Referral to a reproductive endocrinology clinic is indicated in this patient population.


Assuntos
Doenças Autoimunes/tratamento farmacológico , Preservação da Fertilidade/métodos , Imunossupressores/efeitos adversos , Infertilidade Feminina/prevenção & controle , Insuficiência Ovariana Primária/prevenção & controle , Técnicas de Reprodução Assistida , Doenças Autoimunes/complicações , Ciclofosfamida/efeitos adversos , Feminino , Hormônio Liberador de Gonadotropina/agonistas , Hormônio Liberador de Gonadotropina/análogos & derivados , Humanos , Sistema Hipotálamo-Hipofisário , Infertilidade Feminina/etiologia , Infertilidade Feminina/terapia , Insuficiência Ovariana Primária/etiologia , Insuficiência Ovariana Primária/terapia
7.
Clin Epidemiol ; 9: 1-8, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28053555

RESUMO

OBJECTIVE: To characterize antinuclear antibody (ANA) prevalence according to distinct assay methodologies in a pediatric cohort from Mexico City, and to further examine associations with age and sex. METHODS: Serum ANA were measured by indirect immunofluorescence assay (IFA) and multiplex immunoassay in 114 children aged 9-17 years. IFA was considered positive at a cutoff titer of ≥1:80. Agreement between assay methods was assessed by kappa statistic. Sensitivity, specificity, and 95% confidence intervals (CIs) of the multiplex were computed with IFA as the reference standard. RESULTS: Of the 114 children (mean age 14.7 [standard deviation 2.1] years; 54 [47%] female), 18 of 114 (15.8%) were ANA positive by IFA, and 11 of 114 (9.6%) by 11-antigen multiplex assay. ANA prevalence was higher in females compared with males by both of the methods (ratios 1.6-1.9 to 1). Agreement between tests was classified as slight by kappa (κ=0.177 [95% CI -0.051, 0.406]). The multiplex immunoassay had sensitivity of 22.2% (95% CI 6.4, 47.6) and specificity of 92.7% (95% CI 85.6, 97.0), and failed to capture 3 of 4 (75%) of the high-titer (≥1:1280) IFA-positives. CONCLUSION: Up to 15% of children in this general population cohort were ANA positive, with a higher rate of positivity among females according to both assay methods. Substantial discordance in ANA results was found between IFA and multiplex methods, even for high-titer IFA positives. These findings underscore the need to sufficiently account for assay characteristics when interpreting ANA test results, and support IFA as the more appropriate assay for studies of subclinical autoimmunity.

8.
Best Pract Res Clin Rheumatol ; 30(1): 63-80, 2016 02.
Artigo em Inglês | MEDLINE | ID: mdl-27421217

RESUMO

Autoimmune connective tissue diseases predominantly affect women and often occur during the reproductive years. Thus, specialized issues in pregnancy planning and management are commonly encountered in this patient population. This chapter provides a current overview of pregnancy as a risk factor for onset of autoimmune disease, considerations related to the course of pregnancy in several autoimmune connective tissue diseases, and disease management and medication issues before pregnancy, during pregnancy, and in the postpartum period. A major theme that has emerged across these inflammatory diseases is that active maternal disease during pregnancy is associated with adverse pregnancy outcomes, and that maternal and fetal health can be optimized when conception is planned during times of inactive disease and through maintaining treatment regimens compatible with pregnancy.


Assuntos
Doenças Autoimunes/imunologia , Doenças do Tecido Conjuntivo/complicações , Complicações na Gravidez/imunologia , Feminino , Humanos , Gravidez , Resultado da Gravidez , Fatores de Risco
9.
Lupus Sci Med ; 3(1): e000134, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27158525

RESUMO

OBJECTIVE: Systemic lupus erythematosus (SLE) is associated with increased risk of adverse pregnancy outcomes, including pre-eclampsia, particularly in association with antiphospholipid antibody syndrome (APS). While significant placental abnormalities are expected in pre-eclampsia, less is known about how lupus activity and APS in pregnancy affect the placenta. We describe placental pathology from a population of lupus pregnancies, several of which were complicated by APS-related thromboses, in which pre-eclampsia and other complications developed. We performed standard histopathological placental review and quantified neutrophils and neutrophil extracellular traps (NETs) in the intervillous space, given the recognised association of NETs with lupus, APS and pre-eclampsia. METHODS: Pre-eclampsia, SLE and control placentas were scored for histological features, and neutrophils were quantified on H&E and immunohistochemical staining for the granular protein myeloperoxidase. NETs were identified by extracellular myeloperoxidase staining in the setting of decondensed nuclei. Non-parametric analysis was used to evaluate differences in netting and intact neutrophils between groups, with Kruskal-Wallis testing for associations between histological findings and neutrophils. RESULTS: Placentas were evaluated from 35 pregnancies: 10 controls, 11 pre-eclampsia, 4 SLE+pre-eclampsia and 10 SLE, including one complicated by catastrophic APS and one complicated by hepatic and splenic vein thromboses during pregnancy. Intrauterine growth restriction and oligohydramnios were observed in lupus cases but not controls. Significantly more NETs were found infiltrating placental intervillous spaces in pre-eclampsia, SLE+pre-eclampsia and all 10 SLE non-pre-eclampsia cases. The ratio of NETs to total neutrophils was significantly increased in all case groups compared with controls. When present, NETs were associated with maternal vasculitis, laminar decidual necrosis, maternal-fetal interface haemorrhage and non-occlusive fetal thrombotic vasculopathy. CONCLUSIONS: In this pilot study of placental tissue from lupus pregnancies, outcomes were more complicated, particularly if associated with APS. Placental tissue revealed marked inflammatory and vascular changes that were essentially indistinguishable from placental tissue of pre-eclampsia pregnancies.

10.
Am J Public Health ; 105(5): e74-9, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25790387

RESUMO

OBJECTIVES: We assessed the burden of systemic lupus erythematosus (SLE) among Arab and Chaldean Americans residing in southeast Michigan. METHODS: For those meeting SLE criteria from the Michigan Lupus Epidemiology and Surveillance Registry, we determined Arab or Chaldean ethnicity by links with demographic data from birth certificates and with a database of Arab and Chaldean names. We compared prevalence and incidence of SLE for Arab and Chaldean Americans with estimates for non-Arab and non-Chaldean American Whites and Blacks. RESULTS: We classified 54 individuals with SLE as Arab and Chaldean Americans. The age-adjusted incidence and prevalence estimates for Arab and Chaldean Americans were 7.6 and 62.6 per 100 000, respectively. Arab and Chaldean Americans had a 2.1-fold excess SLE incidence compared with non-Arab and non-Chaldean American Whites. Arab and Chaldean American women had both significantly higher incidence rates (5.0-fold increase) and prevalence estimates (7.4-fold increase) than did Arab and Chaldean American men. CONCLUSIONS: Recognizing that Arab and Chaldean Americans experience different disease burdens from Whites is a first step toward earlier diagnosis and designing targeted interventions. Better methods of assigning ethnicity would improve research in this population.


Assuntos
Lúpus Eritematoso Sistêmico/etnologia , Adulto , Árabes , Feminino , Humanos , Incidência , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Prevalência , Vigilância em Saúde Pública , Fatores Socioeconômicos
11.
Environ Health Perspect ; 123(8): 792-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25665152

RESUMO

BACKGROUND: Immune dysregulation associated with mercury has been suggested, although data in the general population are lacking. Chronic exposure to low levels of methylmercury (organic) and inorganic mercury is common, such as through fish consumption and dental amalgams. OBJECTIVE: We examined associations between mercury biomarkers and antinuclear antibody (ANA) positivity and titer strength. METHODS: Among females 16-49 years of age (n = 1,352) from the National Health and Nutrition Examination Survey (NHANES) 1999-2004, we examined cross-sectional associations between mercury and ANAs (indirect immunofluorescence; cutoff ≥ 1:80). Three biomarkers of mercury exposure were used: hair (available 1999-2000) and total blood (1999-2004) predominantly represented methylmercury, and urine (1999-2002) represented inorganic mercury. Survey statistics were used. Multivariable modeling adjusted for several covariates, including age and omega-3 fatty acids. RESULTS: Sixteen percent of females were ANA positive; 96% of ANA positives had a nuclear speckled staining pattern. Geometric mean (geometric SD) mercury concentrations were 0.22 (0.03) ppm in hair, 0.92 (0.05) µg/L blood, and 0.62 (0.04) µg/L urine. Hair and blood, but not urinary, mercury were associated with ANA positivity (sample sizes 452, 1,352, and 804, respectively), after adjusting for confounders: for hair, odds ratio (OR) = 4.10 (95% CI: 1.66, 10.13); for blood, OR = 2.32 (95% CI: 1.07, 5.03) comparing highest versus lowest quantiles. Magnitudes of association were strongest for high-titer (≥ 1:1,280) ANA: hair, OR = 11.41 (95% CI: 1.60, 81.23); blood, OR = 5.93 (95% CI: 1.57, 22.47). CONCLUSIONS: Methylmercury, at low levels generally considered safe, was associated with subclinical autoimmunity among reproductive-age females. Autoantibodies may predate clinical disease by years; thus, methylmercury exposure may be relevant to future autoimmune disease risk.


Assuntos
Anticorpos Antinucleares/sangue , Exposição Ambiental , Poluentes Ambientais/metabolismo , Compostos de Mercúrio/urina , Compostos de Metilmercúrio/metabolismo , Adolescente , Adulto , Antígenos de Superfície/sangue , Biomarcadores/sangue , Biomarcadores/metabolismo , Biomarcadores/urina , Estudos Transversais , Poluentes Ambientais/sangue , Poluentes Ambientais/urina , Feminino , Técnica Indireta de Fluorescência para Anticorpo , Cabelo/química , Humanos , Imunoglobulina G/sangue , Mercúrio/sangue , Mercúrio/metabolismo , Mercúrio/urina , Compostos de Metilmercúrio/sangue , Pessoa de Meia-Idade , Inquéritos Nutricionais , Estados Unidos , Adulto Jovem
12.
Artigo em Inglês | MEDLINE | ID: mdl-28553545

RESUMO

Autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (scleroderma) preferentially affect women, and are characterized by systemic inflammation leading to target organ dysfunction. The public health burden of autoimmune diseases, which collectively represent a leading cause of morbidity and mortality among women throughout adulthood, is substantial. While some features of these diseases have been observed to improve over the menopausal transition, such as disease flare rate in SLE and skin softening and thinning in scleroderma, others, such as swollen and tender joints and radiographically confirmed damage in RA may worsen. The general trends, however, are not consistent or conclusive for all disease-related manifestations. Of great importance is the recognition that comorbid diseases, including osteoporosis and accelerated cardiovascular disease, contribute excess morbidity and mortality that becomes increasingly apparent as women with autoimmune diseases undergo the menopausal transition.

13.
Lupus Sci Med ; 1(1): e000051, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25452880

RESUMO

OBJECTIVES: Patients with systemic lupus erythematosus (SLE) are at higher risk of haematological malignancies (HMs) than the general population. Most reports have focused on HM diagnosed after SLE, and have excluded concurrent and preceding diagnoses. Information on response to therapy is also limited. METHODS: We identified 13 296 cases of HM and 10 539 potential patients with SLE at our centre; 45 patients were confirmed to have HM and SLE. Our retrospective case series was based on these 45 patients. RESULTS: Of the 45 patients, 64% were diagnosed with HM ≥1 year after diagnosis with SLE, and 36% with HM before or concurrent with SLE. Of the 29 patients with HM after SLE, 13 had diffuse large B cell lymphoma (DLBCL), 6 indolent lymphoma, 4 leukaemia, 3 Hodgkin's disease, and 1 each Burkitt's lymphoma, T cell lymphoma and multiple myeloma. Eleven patients with DLBCL were treated with cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone (CHOP) or rituximab-CHOP; hydroxydaunorubicin, oncovin and prednisone; only four achieved durable remission. Of the 16 patients diagnosed with HM before or concurrent with SLE, 9 were diagnosed with HM more than 2 years before SLE and tended to be in remission prior to SLE diagnosis. Seven patients were diagnosed with HM and SLE concurrently; in terms of their HM, six achieved remission or stable disease. CONCLUSIONS: In summary, DLBCL was the most common type of lymphoma in patients diagnosed with HM after SLE; these patients presented with advanced-stage disease and had poor outcomes. In contrast, patients diagnosed with HM before or concurrent with SLE had early stage disease and typically achieved remission.

14.
Lupus Sci Med ; 1(1): e000034, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25379194

RESUMO

INTRODUCTION: Surveys of long-term health and developmental outcomes of children born to mothers with systemic lupus erythematosus (SLE) have suggested an increase in learning disabilities among these children. We performed this observational study to investigate the relationship between maternal autoantibodies and antiphospholipid antibody syndrome (APS) in maternal lupus patients and neurocognitive development among their offspring. METHODS: SLE mothers with at least one live birth postlupus diagnosis were enrolled. Data on maternal medical/obstetric history and children's perinatal/medical history were collected by structured interview and medical record reviews. The primary outcome was requirement for special educational (SE) services, a proxy for developmental delays. Multiple logistic regression modelling was used to examine associations between APS and autoantibodies with SE usage, accounting for SLE disease severity and potential confounders. RESULTS: Data on 38 mothers and 60 offspring were analysed: SE service usage was reported for 15 of 60 (25%) offspring. Maternal APS history was significantly associated with increased use of SE services among offspring, including after adjustment for lupus anticoagulant (LA) positivity and potential confounders (OR 5.5-9.4 for delays age ≥2; p<0.05). The presence of LA, but not other antiphospholipid antibodies, was also associated with increased SE services usage. CONCLUSIONS: Maternal APS and LA were independently associated with increased usage of special educational services among offspring of women with SLE.

15.
Environ Res ; 135: 63-9, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25262076

RESUMO

BACKGROUND: Mercury is a global contaminant of concern though little is known about exposures in México. OBJECTIVES: To characterize mercury levels in pregnant women, children, and commonly consumed seafood samples. METHODS: Use resources of the Early Life Exposures in Mexico to Environmental Toxicants (ELEMENT) birth cohorts to measure total mercury levels in archived samples from 348 pregnant women (blood from three trimesters and cord blood), 825 offspring (blood, hair, and urine) and their mothers (hair), and 91 seafood and canned tuna samples from Mexico City. RESULTS: Maternal blood mercury levels correlated across three trimesters and averaged 3.4 µg/L. Cord blood mercury averaged 4.7 µg/L and correlated with maternal blood from trimester 3 (but not trimesters 1 and 2). In children, blood, hair and urine mercury levels correlated and averaged 1.8 µg/L, 0.6 µg/g, and 0.9 µg/L, respectively. Hair mercury was 0.5 µg/g in mothers and correlated with child's hair. Mean consumption of canned tuna, fresh fish, canned sardine, and shellfish was 3.1, 2.2, 0.5, and 1.0 times per month respectively in pregnant women. Mean mercury content in 7 of 23 seafood species and 5 of 9 canned tuna brands purchased exceeded the U.S. EPA guidance value of 0.3 µg/g. CONCLUSIONS: Mercury exposures in pregnant women and children from Mexico City, via biomarker studies, are generally 3-5 times greater than values reported in population surveys from the U.S., Canada, and elsewhere. In particular, mercury levels in 29-39% of the maternal participants exceeded the biomonitoring guideline associated with the U.S. EPA reference dose for mercury.


Assuntos
Cidades , Exposição Ambiental/análise , Poluentes Ambientais/análise , Contaminação de Alimentos/análise , Mercúrio/análise , Alimentos Marinhos/análise , Animais , Criança , Estudos de Coortes , Monitoramento Ambiental/estatística & dados numéricos , Feminino , Sangue Fetal/química , Cabelo/química , Humanos , Mercúrio/sangue , Mercúrio/urina , México/epidemiologia , Gravidez , Refratometria , Atum/metabolismo
16.
Curr Opin Rheumatol ; 26(3): 321-8, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24646947

RESUMO

PURPOSE OF REVIEW: To review the association of pregnancy with the risk of subsequent development of rheumatic autoimmune diseases in women, including rheumatoid arthritis (RA), systemic lupus erythematosus, and scleroderma. RECENT FINDINGS: There is a small but growing literature related to the risk of autoimmune rheumatic disease in association with pregnancy history. However, results conflict both in terms of the direction and magnitude of risk of disease in relationship to prior pregnancy history. Although anecdotal evidence tends to favor the premise that pregnancy is protective against certain diseases, such as RA, the heterogeneity of results precludes the ability to confirm an association in either direction. There is indication that time elapsed since pregnancy may influence risk, with the postpartum year being of particular relevance. SUMMARY: To date, a clear pattern has not emerged regarding pregnancy and the future risk of autoimmune rheumatic diseases. This topic requires greater study, and given the strong female preponderance of these diseases, future research efforts should seek to resolve this important issue.


Assuntos
Doenças Autoimunes/imunologia , Complicações na Gravidez/imunologia , Doenças Reumáticas/imunologia , Artrite Reumatoide/imunologia , Autoimunidade/imunologia , Feminino , Humanos , Lúpus Eritematoso Sistêmico/imunologia , Gravidez , Fatores de Risco , Escleroderma Sistêmico/imunologia
17.
Arthritis Rheumatol ; 66(2): 369-78, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24504809

RESUMO

OBJECTIVE: To estimate the incidence and prevalence of systemic lupus erythematosus (SLE) in a sociodemographically diverse southeastern Michigan source population of 2.4 million people. METHODS: SLE cases fulfilling the American College of Rheumatology classification criteria (primary case definition) or meeting rheumatologist-judged SLE criteria (secondary definition) and residing in Wayne or Washtenaw Counties during 2002-2004 were included. Case finding was performed from 6 source types, including hospitals and private specialists. Age-standardized rates were computed, and capture-recapture was performed to estimate underascertainment of cases. RESULTS: The overall age-adjusted incidence and prevalence (ACR definition) per 100,000 persons were 5.5 (95% confidence interval [95% CI] 5.0-6.1) and 72.8 (95% CI 70.8-74.8). Among females, the incidence was 9.3 per 100,000 persons and the prevalence was 128.7 per 100,000 persons. Only 7 cases were estimated to have been missed by capture-recapture, adjustment for which did not materially affect the rates. SLE prevalence was 2.3-fold higher in black persons than in white persons, and 10-fold higher in females than in males. Among incident cases, the mean ± SD age at diagnosis was 39.3 ± 16.6 years. Black SLE patients had a higher proportion of renal disease and end-stage renal disease (ESRD) (40.5% and 15.3%, respectively) as compared to white SLE patients (18.8% and 4.5%, respectively). Black patients with renal disease were diagnosed as having SLE at younger age than white patients with renal disease (mean ± SD 34.4 ± 14.9 years versus 41.9 ± 21.3 years; P = 0.05). CONCLUSION: SLE prevalence was higher than has been described in most other population-based studies and reached 1 in 537 among black female persons. There were substantial racial disparities in the burden of SLE, with black patients experiencing earlier age at diagnosis, >2-fold increases in SLE incidence and prevalence, and increased proportions of renal disease and progression to ESRD as compared to white patients.


Assuntos
Monitoramento Epidemiológico , Lúpus Eritematoso Sistêmico/etnologia , Lúpus Eritematoso Sistêmico/epidemiologia , Adulto , Fatores Etários , Grupos de Populações Continentais , Feminino , Humanos , Incidência , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Fatores Sexuais
18.
Am J Obstet Gynecol ; 208(4): 316.e1-6, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23531329

RESUMO

OBJECTIVE: Fetal dysregulation of T helper cell pathways may predispose to allergy, as high cord blood T helper 2/T helper 1 ratios have been shown to precede development of allergic diseases. We aimed to determine whether prenatal eicosapentaenoic acid and docosahexaenoic acid supplementation reduces T helper 2 to T helper 1-associated chemokine ratios. We also explored the effect of mode of delivery on T helper 2/T helper 1 ratios. STUDY DESIGN: We conducted a secondary analysis of a randomized placebo controlled trial initially performed to assess the effects of docosahexaenoic acid or eicosapentaenoic acid supplementation on pregnancy-related depressive symptoms among 126 participants. Cord plasma specimens from 98 newborns were assayed for chemokines associated with T helper 2 (thymus and activation-regulated chemokine [CCL17], macrophage-derived chemokine [CCL22], eotaxin [CCL 11]) and T helper 1 (interferon-inducible protein-10 [CXCL 10]) by enzyme-linked immunosorbent assay and Multiplex immunoassays. Ratios of log-transformed chemokines macrophage-derived chemokine/interferon-inducible protein-10 and thymus and activation-regulated chemokine/interferon-inducible protein-10 were compared between groups by analyses of variance. Multiple linear regression was performed to examine associations between treatments and chemokine ratios, adjusting for covariates. RESULTS: After adjusting for gestational age at delivery, birthweight, and mode of delivery, both omega-3 supplementation groups were associated with lower macrophage-derived chemokine/interferon-inducible protein-10 ratios than placebo (eicosapentaenoic acid: coefficient -1.8; 95% confidence interval [CI], -3.6 to -0.05; P = .04; docosahexaenoic acid: -2.0; 95% CI, -3.9 to -0.07; P = .04). Similar associations were found for thymus and activation-regulated chemokine/interferon-inducible protein-10 (eicosapentaenoic acid: -1.5; 95% CI, -3.0 to 0.06; P = .06; docosahexaenoic acid -2.2; 95% CI, -3.8 to -0.52; P = .01). Cesarean delivery was associated with higher macrophage-derived chemokine/interferon-inducible protein-10 (1.6; 95% CI, 0.01-3.3; P = .049) and thymus and activation-regulated chemokine/interferon-inducible protein-10 (1.5; 95% CI, 0.1-2.9; P = .042) ratios than vaginal delivery. CONCLUSION: Prenatal supplementation with eicosapentaenoic acid and docosahexaenoic acid resulted in decreased cord blood T helper 2/T helper 1 chemokine ratios. Cesarean delivery was associated with a pronounced T helper 2 deviation at birth.


Assuntos
Ácidos Docosa-Hexaenoicos/administração & dosagem , Ácido Eicosapentaenoico/administração & dosagem , Hipersensibilidade/imunologia , Células Th1/imunologia , Células Th2/imunologia , Adulto , Feminino , Humanos , Gravidez
19.
Arthritis Care Res (Hoboken) ; 65(5): 759-66, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23139238

RESUMO

OBJECTIVE: Azathioprine (AZA) is recognized among immunosuppressive medications as relatively safe during pregnancy for women with systemic lupus erythematosus (SLE) requiring aggressive treatment. This pilot study aimed to determine whether SLE therapy during pregnancy was associated with developmental delays in offspring. METHODS: This cohort study included SLE patients with at least one live birth postdiagnosis. Medical histories were obtained via interviews and chart review. Multiple logistic regression was used to examine associations between SLE therapy during pregnancy and maternal report of special educational (SE) requirements (as proxy for developmental delays) among offspring. Propensity scoring (incorporating corticosteroid use, lupus flare, and lupus nephritis) was used to account for disease severity. RESULTS: Of 60 eligible offspring from 38 mothers, 15 required SE services, the most common indication for which was speech delay. Seven (54%) of the 13 children with in utero AZA exposure utilized SE services versus 8 (17%) of 47 nonexposed children (P < 0.01). After adjustment for pregnancy duration, small for gestational age, propensity score, maternal education level, and antiphospholipid antibody syndrome, AZA was significantly associated with SE utilization occurring from age 2 years onward (odds ratio 6.6, 95% confidence interval 1.0-43.3), and bordered on significance for utilization at any age or age <2 years. CONCLUSION: AZA exposure during SLE pregnancy was independently associated with increased SE utilization in offspring, after controlling for confounders. Further research is indicated to fully characterize developmental outcomes among offspring with in utero AZA exposure. Vigilance and early interventions for suspected developmental delays among exposed offspring may be warranted.


Assuntos
Azatioprina/efeitos adversos , Deficiências do Desenvolvimento/epidemiologia , Educação Especial/tendências , Lúpus Eritematoso Sistêmico/epidemiologia , Complicações na Gravidez/epidemiologia , Efeitos Tardios da Exposição Pré-Natal/epidemiologia , Adolescente , Adulto , Criança , Pré-Escolar , Estudos de Coortes , Deficiências do Desenvolvimento/diagnóstico , Deficiências do Desenvolvimento/psicologia , Feminino , Humanos , Lactente , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Masculino , Projetos Piloto , Gravidez , Complicações na Gravidez/tratamento farmacológico , Efeitos Tardios da Exposição Pré-Natal/diagnóstico , Efeitos Tardios da Exposição Pré-Natal/psicologia
20.
Ann Rheum Dis ; 72(4): 525-9, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22586159

RESUMO

OBJECTIVES: To examine the familial risk of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), including juvenile rheumatoid/idiopathic arthritis (JRA), in a population-based setting; and to determine whether patterns of transmission differ according to the sex of the parent or offspring, in order to provide insight into the potential impact of X-chromosomal factors on sex disparities in these autoimmune diseases. METHODS: A population-based cohort of parent-offspring triads from Denmark (1977-2010) was established. SLE and RA incidence rates among offspring were calculated, and Cox regression was performed to assess the sex-specific risk of disease in offspring according to maternal or paternal disease history. RESULTS: Among 3 513 817 parent-offspring triads, there were 1258 SLE cases among offspring (1095 female, 163 male) and 9118 cases of RA/JRA (6086 female, 3032 male). Among female offspring, SLE risk was nearly the same according to maternal (HR 14.1) or paternal (HR 14.5) history (p=NS); likewise among male offspring, risk according to maternal (HR 5.5) and paternal (no cases) history were similar (p=NS). For RA, all risk estimates were similar, regardless of the sex of the offspring or parent (HR 2.6-2.9; p=NS). CONCLUSIONS: The authors quantified the familial risk of SLE and RA in a nationwide cohort study. For both diseases, transmission was comparable among both female and male offspring of maternal and paternal cases. These data provide evidence at the population level that X-chromosomal factors do not play a major role in sex disparities associated with the risk of SLE and RA.


Assuntos
Artrite Juvenil/epidemiologia , Artrite Juvenil/genética , Artrite Reumatoide/epidemiologia , Artrite Reumatoide/genética , Lúpus Eritematoso Sistêmico/epidemiologia , Lúpus Eritematoso Sistêmico/genética , Adulto , Filho de Pais Incapacitados/estatística & dados numéricos , Cromossomos Humanos X/genética , Estudos de Coortes , Dinamarca/epidemiologia , Feminino , Predisposição Genética para Doença/epidemiologia , Humanos , Incidência , Masculino , Pais , Fatores de Risco , Distribuição por Sexo
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