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1.
Ann Rheum Dis ; 2021 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-33452003

RESUMO

OBJECTIVE: To determine the ominosity of the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) Systemic Lupus Erythematosus Classification Criteria by determining its predictive role for disease severity in the first 5 years following diagnosis. METHODS: 867 patients with systemic lupus erythematosus (SLE) from the Toronto Lupus Clinic were included (all first 12 months after SLE diagnosis). The EULAR/ACR criteria score was calculated based on baseline information. To determine disease severity in the first 5 years after diagnosis, adjusted mean SLE Disease Activity Index 2000 (AMS), flares, remission and immunosuppressive treatment were used as outcomes. The Systemic Lupus International Collaborating Clinics (SLICC) registry comprised the validation cohort. RESULTS: Based on receiver operating characteristic analysis, a EULAR/ACR score of 20 was used as a threshold to compare outcomes between groups. In the first 5 years of disease course, patients with a score of ≥20 had higher AMS scores (p<0.001) and were more likely to ever experience a flare (p<0.001). These patients had lower probabilities of achieving remission and higher requirements for immunosuppressives. Results were confirmed in the SLICC validation cohort. Patients with a score of ≥20 had higher AMS during the first 5 years of disease (5.4 vs 3.1% and ≥20 vs <20 respectively, p≤0.001). The score correlated with AMS (r=0.43, p≤0.001) in the same time frame. CONCLUSION: A EULAR/ACR score of ≥20 is an indicator of ominosity in SLE. Patients with a score of ≥20 were characterised by a more active disease course throughout the first 5 years. These criteria provide prognostic information regarding disease severity in the first 5 years following diagnosis.

2.
Lupus ; : 961203320983892, 2021 Jan 07.
Artigo em Inglês | MEDLINE | ID: mdl-33413006

RESUMO

OBJECTIVES: Fatigue is one of the most common symptoms reported in patients living with SLE. We aim to: 1) determine if different trajectories of fatigue associate with specific latent classes of disease activity and 2) define the patient characteristics and associated factors in different latent classes. METHODS: Data from an inception cohort of adult patients from the Toronto Lupus Clinic from 1997-2018 were analyzed. Fatigue levels were measured using Fatigue Severity Scale (FSS) and disease activity by the Adjusted Mean Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) (AMS). Dual latent class trajectory analysis, for fatigue and AMS, was performed. Univariable and multivariable logistic regression analyses assessed the association of baseline variables with class membership. RESULTS: Among 280 patients, 4 dual classes (C) of fatigue and disease activity were identified: C1- lowest disease activity and second highest fatigue trajectory (27%); C2- second highest disease activity and highest fatigue trajectory (30%); C3-moderate disease activity and lowest fatigue trajectory (33%); and C4- highest disease activity and moderate fatigue trajectory (10%). CONCLUSION: 4 distinct latent classes of dual fatigue and disease activity trajectories were identified. Fatigue and disease activity follow distinct trajectories and disease activity alone cannot fully explain fatigue trajectories. Trajectories with higher FSS scores were associated with more fibromyalgia and trajectories with higher disease activity were associated with higher cumulative glucocorticoid use. Higher baseline glucocorticoid use was more likely associated with more fatigue while older age at SLE diagnosis was associated with less fatigue.

3.
J Rheumatol ; 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-33259331

RESUMO

OBJECTIVE: Lupus nephritis (LN) may lead to end-stage kidney disease (ESKD) in 22% of patients over 15 years with the risk being particularly higher in diffuse proliferative forms. The rate of kidney function decline varies. However, a catastrophic course leading to ESKD within a few years from onset is uncommon. The aim of the present study was to assess the factors associated with rapid progression to ESKD in LN patients. METHODS: Patients from the Toronto Lupus Clinic with biopsy-proven LN at presentation and eGFR≥60ml/min/1.73m2 who developed ESKD within three years were retrieved. Pathology reports were reviewed with particular emphasis on distinct histopathologic features. Demographic, clinical, laboratory and therapeutic variables were also analyzed. RESULTS: Ten patients (1.8% of the total LN population) developed ESKD within three years of diagnosis. Their mean age was 34.2±7.3 years, mean time to ESKD 19.2±12.4 months, initial eGFR=90.2±24.9ml/min/1.73m2, proteinuria 2.7±1.04 grams/24h. The rate of kidney function decline was more than 43ml/min/1.73m2/year (median). One patient had LN class III, five had LN class IV, two membranous LN (class V) and another two had mixed IV/V. Moreover, two patients had extensive thrombotic microangiopathy, one collapsing glomerulonephritis and one concomitant anti-glomerular basement membrane (anti-GBM) nephropathy. Four patients showed no unusual kidney pathology; all of them had severe non-compliance (discontinued all medications to follow alternative treatment). CONCLUSION: Catastrophic progression to ESKD is uncommon in LN. The major associated factors are poor compliance and distinct histopathologic features such as thrombotic microangiopathy, collapsing glomerulopathy and concomitant anti-GBM nephropathy.

4.
Artigo em Inglês | MEDLINE | ID: mdl-33140092

RESUMO

OBJECTIVES: Most randomized controlled trials (RCTs) in SLE have failed to reach their respective end points, with the rates of response to placebo (plus standard-of-care treatment) being unexpectedly high. The aim of this systematic review was to quantify the response to placebo in non-renal, non-neuropsychiatric lupus. METHODS: The PubMed database was searched (from 2000 to December 2019) for phase II/III RCTs assessing the efficacy and safety of biologics in non-renal, non-neuropsychiatric SLE. Data on the efficacy and safety of the placebo-treated patients were collected in a pre-established data retrieval form. Descriptive statistics were used. RESULTS: A total of 24 RCTs (n = 11 128 in total) were included. Placebo-treated patients (n = 3899) were mostly females (93.5%), Caucasians (60.2%), of mean age 39.7 years, and having a mean disease duration of 7.4 years. Their mean initial SLEDAI 2000 was 10.4, whereas 60.5% had positive anti-dsDNA antibodies, 41.9% low C3 and 35.6% low C4 at randomization. Standard-of-care treatment included glucocorticosteroids in 85.9%, antimalarials in 72.8% and immunosuppressives in 48.5%. The response to placebo was 36.2% for the primary end point (as defined in each study), 39.8% for the SLE Responder Index-4 (SRI-4), 29.2% for SRI-5, 28.4% for SRI-6 and 30.9% for BILAG-based Combined Lupus Assessment response. Regarding safety, there were serious adverse events in 16.3% of patients, serious infections in 5.5% and malignancies in 0.3%, and death occurred in 0.56% of patients. CONCLUSION: More than one-third of the placebo-treated patients achieved their respective primary end points in RCTs with biologics in non-renal, non-neuropsychiatric SLE. The response rate was higher for certain end points, such as the SRI-4, while it decreased with more stringent end points.

5.
Artigo em Inglês | MEDLINE | ID: mdl-33006611

RESUMO

OBJECTIVE: Infection is a leading cause of death in the SLE population. Low immunoglobulin levels might be a potential risk for infection. We aimed to assess whether acquired low levels of any type of immunoglobulin increase the risk of clinically relevant infection in adult patients with SLE. METHODS: We compared adult SLE patients who had acquired any low immunoglobulin levels (IgA, IgM or IgG) for 2 years with patients with normal or high levels with respect to clinically relevant infection (defined as infections requiring intravenous or oral antibiotics) in a prospective cohort study. Group balance was achieved using propensity score adjustment, matching and inverse probability weighting. Primary analysis was time to event using Cox-regression modelling adjusting for potential confounders. Sensitivity analyses were conducted to examine several exposure and outcome definitions. RESULTS: Patients with hypogammaglobulinaemia had longer disease duration, more lupus nephritis history, higher proteinuria and more accumulated damage. Low IgA level was associated with increased risk of clinically relevant infection [hazard ratio (HR): 2.24, 95% CI: 1.61, 3.12] while low IgG (HR: 1.15, 95% CI: 0.84, 1.59) or low IgM (HR: 0.95, 95% CI: 0.73, 1.23) was not. Low immunoglobulin recovery in the first year was 2.5% (11), second year 8.2% (36), third year 10.1% (44) and fourth year 18.4% (80), and 60% (263) of acquired hypogammaglobulinaemia recovered over 4 years. CONCLUSION: The majority of acquired hypogammaglobulinaemia in adult patients with SLE is transient. Only low acquired IgA was associated with increased risk of infection among adult patients with SLE. Whether immunoglobulin replacement provides additional protective effect requires further investigation.

6.
Arthritis Rheumatol ; 72(10): 1734-1740, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32515554

RESUMO

OBJECTIVE: In previous studies, atherosclerotic vascular events (AVEs) were shown to occur in ~10% of patients with systemic lupus erythematosus (SLE). We undertook this study to investigate the annual occurrence and potential risk factors for AVEs in a multinational, multiethnic inception cohort of patients with SLE. METHODS: A large 33-center cohort of SLE patients was followed up yearly between 1999 and 2017. AVEs were attributed to atherosclerosis based on SLE being inactive at the time of the AVE as well as typical atherosclerotic changes observed on imaging or pathology reports and/or evidence of atherosclerosis elsewhere. Analyses included descriptive statistics, rate of AVEs per 1,000 patient-years, and univariable and multivariable relative risk regression models. RESULTS: Of the 1,848 patients enrolled in the cohort, 1,710 had ≥1 follow-up visit after enrollment, for a total of 13,666 patient-years. Of these 1,710 patients, 3.6% had ≥1 AVEs attributed to atherosclerosis, for an event rate of 4.6 per 1,000 patient-years. In multivariable analyses, lower AVE rates were associated with antimalarial treatment (hazard ratio [HR] 0.54 [95% confidence interval (95% CI) 0.32-0.91]), while higher AVE rates were associated with any prior vascular event (HR 4.00 [95% CI 1.55-10.30]) and a body mass index of >40 kg/m2 (HR 2.74 [95% CI 1.04-7.18]). A prior AVE increased the risk of subsequent AVEs (HR 5.42 [95% CI 3.17-9.27], P < 0.001). CONCLUSION: The prevalence of AVEs and the rate of AVE accrual demonstrated in the present study is much lower than that seen in previously published data. This may be related to better control of both the disease activity and classic risk factors.

7.
Artigo em Inglês | MEDLINE | ID: mdl-32526080

RESUMO

BACKGROUND: Cognitive function may change over time in patients with SLE, and cognitive function trajectories have not well been studied. We aim to: 1) identify cognitive function trajectories in SLE and describe it with depressive symptoms trajectories and 2) identify baseline factors associated with class membership in the dual trajectories. METHODS: Longitudinal data from the University of California San Francisco Lupus Outcomes Study were analyzed. Two outcome trajectories were studied jointly - The Hopkins Verbal Learning Test-Revised (HVLT-R) and the Center of Epidemiologic Studies Depression Scale (CES-D) (administered annually). Univariate/multivariable logistic regression analyses examined baseline factors associated with class memberships. RESULTS: 755 patients were studied. 4 latent classes were identified: 1-low CES-D scores and low cognitive scores (no depression + cognitive impairment; 20%), 2-lowest CES-D scores and highest normal cognitive scores (no depression + normal cognition; 48%), 3-highest CES-D scores and lowest cognitive scores (depression + cognitive impairment; 9%), and 4-high CES-D scores and cognitive score at borderline (depression + borderline cognition; 23%). CONCLUSION: 4 distinct classes of dual cognitive function and the depressive symptoms were identified. Persistently low cognitive performance in 28% of patients (Classes 1 and 3) did not significantly improve over 7 years. Cognitive impairment was associated with depression status in 9% of patients (class 3). Other factors also predicted latent class membership; ethnicity, education, disease activity, physical functioning and bodily pain. These results highlight the importance of periodic assessment of cognitive function, and different aspects relevant for assessing and managing cognitive function over time in SLE.

8.
Artigo em Inglês | MEDLINE | ID: mdl-32433815

RESUMO

OBJECTIVE: To compare the performance of Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) and SLEDAI-2K glucocorticoids (SLEDAI-2KG) indices in identifying responders to standard of care (SoC) therapy. METHODS: Data from adult patients seen between 1995-2018 at the University of Toronto Lupus Clinic was analyzed. Patients with active disease (SLEDAI-2K ≥6) and on prednisone ≥ 5 mg/day, and with a follow up visit at 9 months were studied. Response to SoC therapy, at first follow up visit, was assessed by SLEDAI-2K and SLEDAI-2KG. The performances of SLEDAI-2K and SLEDAI-2KG were compared using a cut-off point of 4. RESULTS: In a cohort of 188, the majority were female (86.0%) and Caucasian (47.9%). Of 188 patients, 145 (77.1%) were responders and had a decrease in SLEDAI-2K score of ≥4. SLEDAI-2KG identified 142 (97.9%) responders of SLEDAI-2K responders. More importantly, SLEDAI-2KG identified 11 (25.6%) additional responders among SLEDAI-2K non-responders (n=43). This resulted from the ability of SLEDAI-2KG to account for the decrease in glucocorticoids dose. CONCLUSIONS: SLEDAI-2KG provides a novel concept for the assessment of lupus disease activity while accounting for glucocorticoids dose to reflect on disease activity overall at a particular visit. SLEDAI-2KG accounts for the disease activity for each descriptor while also accounting for the current glucocorticoids dose. SLEDAI-2KG adds one additional variable (corticosteroid dose) to SLEDAI-2K which could alter response rates in drug trials and observational studies.

9.
J Rheumatol ; 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32238510

RESUMO

OBJECTIVE: To examine the role of disease activity on organ damage over 5 years in patients with active systemic lupus erythematosus (SLE) despite standard of care. METHODS: This analysis of the University of Toronto Lupus Clinic cohort assessed organ damage [measured by Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI)] in patients with active SLE [SLE Disease Activity Index 2000 (SLEDAI-2K) ≥ 6], using Cox proportional time-independent hazard models. Subgroup analyses were conducted in patients with SLEDAI-2K 6 or 7, 8 or 9, and ≥ 10 at baseline, and in the overall study population by steroid dose at study entry (< 7.5 vs ≥ 7.5 mg/day). RESULTS: Among the overall study population (n = 649), SDI progression was observed in 209 (32.2%) patients over the 5-year follow-up period. Mean SDI change in patients with a score > 0 was generally consistent across all SLEDAI-2K subgroups. Multivariable analyses identified age at study start (HR 1.03, P < 0.0001), steroid dose (HR 2.03, P < 0.0001), immunosuppressants (HR 1.44, P = 0.021), and SLEDAI-2K (subgroup analyses HR 1.64-2.03, P = 0.0017 to < 0.0001) as the greatest risk factors for SDI progression, while a study start date after the year 2000 had a protective effect on SDI progression compared with a start date prior to the year 2000 (HR 0.65, P = 0.0004). CONCLUSION: Patients within the higher SLEDAI-2K subgroups at study entry or receiving high doses of steroids were more likely to have organ damage progression.

10.
J Rheumatol ; 47(9): 1366-1373, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32238519

RESUMO

OBJECTIVE: Advanced chronic kidney disease (CKD) carries an increased risk for progression to endstage renal disease (ESRD). We aimed to determine the rate of progression and the factors that drive the decline of renal function in lupus nephritis (LN). METHODS: Patients with advanced LN-related CKD were identified from our longterm longitudinal cohort. Advanced CKD was defined as stage 3b [estimated glomerular filtration rate (eGFR) = 30-44 ml/min/1.73 m2] and stage 4 (eGFR = 15-29 ml/min/1.73 m2). All individuals were followed until progression to ESRD or the last visit and were divided into "progressors" and "non- progressors." Demographic, clinical, immunological, and therapeutic variables were compared at baseline. Multivariable Cox regression analysis (both time-dependent and independent) was performed to identify predictors for progression. RESULTS: One hundred eighteen patients (74 CKD 3b and 44 CKD 4) were included. Forty-five patients progressed (29 to ESRD and 16 from CKD 3b to CKD 4) after 6 years on average. No significant decline in the renal function was observed in 73 patients ("non-progressors") after 10 years on average. Active serology (high anti-dsDNA titers and low complements C3/C4) at the time of CKD diagnosis and any increase of the daily prednisone dose after baseline were strongly associated with progression. Treatment with renin angiotensin system (RAS) blockers was associated with less risk for progression. CONCLUSION: Dialysis is not inevitable in LN-related advanced CKD because 62% of our patients did not progress over 10 years of followup on average. Certain predictors were identified to affect progression to ESRD.

11.
Ann Rheum Dis ; 79(5): 612-617, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32156706

RESUMO

BACKGROUND: The 2017 American College of Cardiology/American Heart Association guidelines defined hypertension at ≥130/80 mm Hg. Studies on patients with connective tissue diseases were not considered. Our aim was to assess the impact of this definition on atherosclerotic vascular events (AVEs) in systemic lupus erythematosus. PATIENTS METHODS: Individuals from the Toronto Lupus Clinic with at least 2 years of follow-up and no prior AVE were divided in three groups according to their mean blood pressure (BP) over that period (≥140/90 mm Hg, 130-139/80-89 mm Hg and <130/80 mm Hg). They were followed until the first occurrence of an AVE (fatal or non-fatal coronary artery disease, cerebrovascular event and peripheral vascular disease) or last visit. Groups were compared as per the baseline atherosclerotic risk factors. A multivariable time-dependent analysis was performed to adjust for the presence of other risk factors. RESULTS: Of 1532 patients satisfying the inclusion criteria, 155 (10.1%) had a BP ≥140/90 mm Hg, 316 (20.6%) 130-139/80-89 mm Hg and 1061 (69.3%) were normotensives. After a mean follow-up of 10.8 years, 124 AVEs were documented. The incidence rates were 18.9, 11.5 and 4.5 per 1000 patient-years for the three groups, respectively (p=0.0007 between the 130-139/80-89 mm Hg group and the normotensives). A mean BP of 130-139/80-89 mm Hg over the first 2 years was independently associated with the occurrence of AVEs (HR 1.73, 95% CI 1.13 to 2.65, p=0.011). CONCLUSION: Patients with lupus with a sustained mean BP of 130-139/80-89 mm Hg over 2 years had a significantly higher incidence of AVEs compared with normotensive individuals. This BP level should be the target for antihypertensive therapy to minimise their cardiovascular risk.


Assuntos
Doença da Artéria Coronariana/epidemiologia , Hipertensão/epidemiologia , Lúpus Eritematoso Sistêmico/epidemiologia , Infarto do Miocárdio/epidemiologia , American Heart Association , Análise de Variância , Anti-Hipertensivos/uso terapêutico , Cardiologia/normas , Estudos de Coortes , Doença da Artéria Coronariana/diagnóstico , Feminino , Hospitais Universitários , Humanos , Hipertensão/classificação , Hipertensão/tratamento farmacológico , Lúpus Eritematoso Sistêmico/diagnóstico , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/diagnóstico , Ontário , Prevalência , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Sociedades Médicas , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Análise de Sobrevida , Estados Unidos
12.
Rheumatology (Oxford) ; 59(11): 3211-3220, 2020 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-32221602

RESUMO

OBJECTIVES: To study the clinical phenotypes, determined based on cumulative disease activity manifestations, and sociodemographic factors associated with depression and anxiety in SLE. METHODS: Patients attending a single centre were assessed for depression and anxiety. SLE clinical phenotypes were based on the organ systems of cumulative 10-year SLE Disease Activity Index 2000 (SLEDAI-2K), prior to visit. Multivariable logistic regression analyses for depression, anxiety, and coexisting anxiety and depression were performed to study associated SLE clinical phenotypes and other factors. RESULTS: Among 341 patients, the prevalence of anxiety and depression was 34% and 27%, respectively, while 21% had coexisting anxiety and depression. Patients with skin involvement had significantly higher likelihood of anxiety compared with patients with no skin involvement [adjusted odds ratio (aOR) = 1.8; 95% CI: 1.1, 3.0]. Patients with skin involvement also had higher likelihood of having coexisting anxiety and depression (aOR = 2.0, 95% CI: 1.2, 3.9). Patients with musculoskeletal (MSK) (aOR = 1.9; 95% CI: 1.1, 3.5) and skin system (aOR = 1.8; 95% CI: 1.04, 3.2) involvement had higher likelihood of depression compared with patients without skin or musculoskeletal involvement. Employment status and fibromyalgia at the time of the visit, and inception status were significantly associated with anxiety, depression, and coexisting anxiety and depression, respectively. CONCLUSION: SLE clinical phenotypes, specifically skin or MSK systems, along with fibromyalgia, employment and shorter disease duration were associated with anxiety or depression. Routine patient screening, especially among patients with shorter disease duration, for these associations may facilitate the diagnosis of these mental health disorders, and allow for more timely diagnosis.

13.
Rheumatology (Oxford) ; 59(10): 3032-3041, 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-32191334

RESUMO

OBJECTIVES: To examine for latent patterns of SLE disease activity trajectories that associate with specific latent patterns of health-related quality of life (HRQoL; Medical Outcomes Study Short Form-36), and to determine baseline predictors of class membership. METHODS: In this retrospective longitudinal inception cohort of 222 SLE adults over 10 years, trajectories of three outcomes were studied jointly: Short Form-36 physical (PCS) and mental (MCS) component summaries and adjusted mean SLEDAI-2000 (AMS). Group-based joint trajectory modelling was used to model latent classes; univariable and multivariable analyses were used to identify predictors of class membership. RESULTS: Four latent classes were identified: Class 1 (C1) (24%) had moderate AMS, and persistently low PCS and MCS; C2 (26%) had low AMS, moderate PCS and improved then worsened MCS; C3 (38%) had moderate AMS, and persistently high PCS and MCS; and C4 (11%) had high AMS, moderate-low PCS and improving MCS. Baseline older age was associated with lower HRQoL trajectories. Higher AMS trajectories did not associate with a particular pattern of HRQoL trajectory. A higher prevalence of fibromyalgia (44% in C1) was associated with worse HRQoL trajectories. Disease manifestations, organ damage and cumulative glucocorticoid were not differentially distributed across the latent classes. CONCLUSION: High disease activity did not necessarily associate with low HRQoL. More patients with worse HRQoL trajectories had fibromyalgia. Older age at diagnosis increased the probability of belonging to a class with low HRQoL trajectories. The care of SLE patients may be improved through addressing fibromyalgia in addition to disease activity.

14.
J Rheumatol ; 47(1): 66-71, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30709950

RESUMO

OBJECTIVE: Atherosclerotic vascular events (AVE) are a major cause of mortality and morbidity in systemic lupus erythematosus (SLE). We aimed to determine the effect of early recognition and therapy for both classic risk factors for AVE and for SLE, on the burden of AVE in SLE in recent decades. METHODS: Inception patients who entered the University of Toronto Lupus Clinic between 1975 and 1987 followed to 1992 (Cohort 1), and between 1999 and 2011 followed to 2016 (Cohort 2) were studied. AVE attributed to atherosclerosis and occurring during the 17 years were identified. SLE disease activity and therapy as well as hypertension, hypercholesterolemia, hyperglycemia, and smoking were assessed. Analysis included descriptive statistics on baseline characteristics, traditional risk factors over the followup, outcome rates by each 100 person-years (PY), Kaplan-Meier cumulative AVE curves, as well as competing risk Cox models adjusted by inverse probability weights. RESULTS: Of the 234 patients in Cohort 1, 26 patients (11%) had an AVE compared with 10 of 262 patients (3.8%) in Cohort 2. The rate per 100 PY of followup was 1.8 in Cohort 1 and 0.44 in Cohort 2 (p < 0.0001). Better control of all risk factors and disease activity was achieved in Cohort 2. There was a reduction of 60% in the risk for AVE in Cohort 2. CONCLUSION: The incidence of AVE in SLE in the modern era has declined in large part owing to more effective management of classic coronary artery risk factors and of SLE.

15.
Arthritis Care Res (Hoboken) ; 72(12): 1809-1819, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31628718

RESUMO

OBJECTIVE: Screening for cognitive impairment in systemic lupus erythematosus (SLE) conventionally relies on the American College of Rheumatology (ACR) neuropsychologic battery (NB), which is not universally available. To develop a more accessible screening approach, we assessed validity of the Automated Neuropsychological Assessment Metrics (ANAM). Using the ACR NB as the gold standard for cognitive impairment classification, the objectives were 1) to measure overall discriminative validity of the ANAM for cognitive impairment versus no cognitive impairment, 2) to identify ANAM subtests and scores that best differentiate patients with cognitive impairment from those with no cognitive impairment, and 3) to derive ANAM composite indices and cutoffs. METHODS: A total of 211 consecutive adult patients, female and male, with SLE were administered the ANAM and ACR NB. 1) For overall discriminative validity of the ANAM, we compared patients with cognitive impairment versus those with no cognitive impairment on 4 scores. 2) Six ANAM models using different scores were developed, and the most discriminatory subtests were selected using logistic regression analyses. The area under the receiver operating characteristic curve (AUC) was calculated to establish ANAM validity against the ACR NB. 3) ANAM composite indices and cutoffs were derived for the best models, and sensitivities and specificities were calculated. RESULTS: Patients with no cognitive impairment performed better on most ANAM subtests, supporting ANAM's discriminative validity. Cognitive impairment could be accurately identified by selected ANAM subtests with top models, demonstrating excellent AUCs of 81% and 84%. Derived composite indices and cutoffs demonstrated sensitivity of 78-80% and specificity of 70%. CONCLUSION: This study provides support for ANAM's discriminative validity for cognitive impairment and utility for cognitive screening in adult SLE. Derived composite indices and cutoffs enhance clinical applicability.

16.
Semin Arthritis Rheum ; 50(1): 84-94, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31303437

RESUMO

OBJECTIVES: To systematically review and synthesize literature on 1) the overall prevalence of depression and anxiety in SLE patients in identified studies, and 2) the pooled prevalence per metrics of depression and anxiety in adult SLE patients. METHODS: This review used (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA guidelines and in-depth searches in four databases (1954-2016; Ovid-based Medline, Embase, PsycINFO and CINAHL) to identify articles on the prevalence of depression and/or anxiety in adult SLE patients. Included studies were critically appraised and analyzed. The prevalence of depression and anxiety was studied for all included studies, and whenever possible, pooled prevalence (PP) was determined for more commonly used metrics. Statistical and publication bias was assessed using funnel plots. RESULT: A total of 3103 references were identified, 226 were selected for detailed review and 72 were included in the final analysis. OVERALL PREVALENCE: The depression PP, obtained from 69 studies representing 23,386 SLE patients, was 35.0% (95% CI: 29.9%-40.3%). The anxiety PP, obtained from 38 studies representing 4439 SLE patients, was 25.8% (95% CI: 19.2%-32.9%). PREVALENCE PER METRICS USED: The more commonly used instruments included the Centre for Epidemiological Studies - Depression (CES-D), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Hospital Anxiety and Depression Scales (HADS-A/D), and Hamilton Rating Scales for Depression/Anxiety (HAM-D/A)]. The CES-D was utilized in 13 studies including 1856 SLE patients; depression PP was 41.5% (95% CI: 35.1%-48.1%). The BDI was utilized in 14 studies including 1355 SLE patients and the BAI in 3 studies including 489 patients; depression PP was 39.9% (95% CI: 31.1%-49.1) and anxiety PP was 38.4% (95% CI: 34.2%-42.8%). The HADS-D was utilized in 14 studies including 1238 SLE patients and the HADS-A in 12 studies including 1099 patients respectively; its depression PP was 24.4% (95% CI: 19.1%-30.1%) and anxiety PP was 38.3% (95% CI: 29.1%-47.9%). The HAM-D was utilized in 4 studies including 267 SLE patients and the HAM-A in 4 studies including 213 patients respectively; its depression PP was 40.0% (95% CI: 23.0%-59.0%) and anxiety PP was 39.0% (95% CI: 32.0%-45.0%). CONCLUSION: There was high variability in the prevalence of depression and anxiety, ranging from 8.7%-78.6% and 1.1%-71.4%, respectively. This could be attributed to the lack of consistency in the metrics used and its definition for depression and anxiety in SLE. Studies that used a specific metric, such as the CES-D, BDI or HAM-D, yielded similar depression prevalence. The HADS-D had the lowest prevalence. All metrics of anxiety yielded similar anxiety prevalence.

17.
World J Clin Cases ; 7(20): 3341-3346, 2019 Oct 26.
Artigo em Inglês | MEDLINE | ID: mdl-31667189

RESUMO

BACKGROUND: Hydrofluoric acid (HF) is one of the most common causes of chemical burns. HF burns can cause wounds that deepen and progress aggressively. As a result, HF burns are often severe even if they involve a small area of the skin. Published cases of HF burns have mostly reported small HF burn areas. Few cases of HF inhalation injury have been reported to date. CASE SUMMARY: A 24-year-old man suffered from extensive hydrofluoric acid burns covering 60% of the total body surface area (TBSA), including deep second degree burns on 47% and third degree burns on 13% of the TBSA, after he fell into a pickling pool containing 15% HF. Comprehensive treatments were carried out after the patient was admitted. Ventricular fibrillation occurred 9 times within the first 2 h, and the lowest serum Ca2+ concentration was 0.192 mmol/L. A dose of calcium gluconate (37 g) was intravenously supplied during the first 24 h, and the total amount of calcium gluconate supplementation was 343 g. Extracorporeal membrane oxygenation (ECMO) was applied for 8 d to handle the acute respiratory distress syndrome (ARDS) induced by the HF inhalation injury. The patient was discharged after 99 d of comprehensive treatment, including skin grafting. CONCLUSION: Extensive HF burns combined with an inhalation injury led to a potentially fatal electrolyte imbalance and ARDS. Adequate and timely calcium supplementation and ECMO application were the keys to successful treatment of the patient.

19.
Semin Arthritis Rheum ; 49(2): 260-266, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30940467

RESUMO

OBJECTIVES: This study aimed to: 1) determine the prevalence of depression and anxiety in SLE patients using the Center for Epidemiological Studies-Depression Scale [CES-D], Hospital Anxiety and Depression Scale [HADS], and Beck Anxiety Inventory [BAI] questionnaires; 2) study the criterion validity, interpretability, and test-retest reliability of CES-D, HADS and BAI; and 3) evaluate their diagnostic accuracy when compared to the assessment of an independent psychiatric assessment using the Mini-International Neuropsychiatric Interview (MINI). METHODS: 159 consecutive SLE participants were screened for depression and anxiety using the CES-D, HADS, and BAI, and underwent the MINI. Sensitivity and specificity were evaluated against the MINI. Test-retest reliability was studied. Receiver operator characteristic (ROC) curves were utilized to determine the cut-off scores for CES-D, HADS and BAI. RESULTS: The prevalence of depression ranged from 29% (HADS-D) to 52% (CES-D) and the prevalence of anxiety ranged from 45% (BAI) to 50% (HADS-A). ROC showed similar performance for CES-D and HADS-D. The diagnostic accuracy of HADS-A outperformed BAI. Furthermore, these self-reported questionnaires demonstrated good to excellent test-retest reliability. Analyses exhibited optimal cut-offs for CES-D (26), BAI (19), HADS-A (6), and HADS-D (8) that optimized their sensitivity and specificity as screening metrics for depression and anxiety in SLE patients. CONCLUSIONS: Anxiety and depression are highly prevalent in patients with SLE. Patient-reported outcome questionnaires such as the CES-D, HADS, and BAI may be useful tools to screen for depression and anxiety in SLE. Our results suggest that SLE-specific cut-offs may improve diagnostic accuracy of current screening metrics in patients with lupus.


Assuntos
Ansiedade/epidemiologia , Depressão/epidemiologia , Lúpus Eritematoso Sistêmico/epidemiologia , Adulto , Idoso , Comorbidade , Estudos Transversais , Feminino , Humanos , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Prevalência , Psicometria , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Inquéritos e Questionários
20.
Ann Rheum Dis ; 78(6): 802-806, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30992296

RESUMO

BACKGROUND: Survival in systemic lupus erythematosus (SLE) has improved substantially in the last 50 years. The aim of the present study was to assess the evolution of the all-cause, cause-specific and age-specific standardised mortality ratios (SMRs) of patients with lupus in Ontario, Canada. PATIENTS AND METHODS: Between 1971 and 2013, 1732 patients were followed in the Toronto Lupus Clinic. Causes of death were retrieved from death certificates, autopsy reports, hospital records or the records of the family physicians. They were categorised as atherosclerotic, infectious, malignancy, active lupus and others. For the calculation of the SMR (indirect standardisation method), data from the general population of Ontario, Canada were used (Statistics Canada). RESULTS: Two hundred and forty-nine patients (205 women) died (infections 24.5%, atherosclerosis 15.7%, active lupus 13.3%, malignancy 9.6%); mean age was 53.2±16.6 years and mean disease duration 15.2±11.7 years. The all-cause SMR was substantially decreased from the 1970s (13.5, 95% CI 8.6 to 18.5) to recent years (2.2, 95% CI 1.4 to 3.1). Similar trends were observed for atherosclerosis, infections and malignancies over time. The all-cause age-specific SMR was particularly high in younger (19-39 years old) patients (SMR=12.4, 95% CI 9.7 to 15.1) as compared with individuals older than 40 years (SMR=3.1, 95% CI 2.6 to 3.6). The cause-specific SMR was also higher in younger patients, particularly for infections and malignancies. CONCLUSIONS: The all-cause and cause-specific SMR significantly decreased over time, likely reflecting the advances in the management of SLE and certain comorbidities. The all-cause and cause-specific SMR was particularly high for younger patients (<40 years old).


Assuntos
Lúpus Eritematoso Sistêmico/mortalidade , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Aterosclerose/complicações , Aterosclerose/mortalidade , Causas de Morte , Atestado de Óbito , Feminino , Humanos , Estudos Longitudinais , Lúpus Eritematoso Sistêmico/complicações , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Neoplasias/complicações , Neoplasias/mortalidade , Ontário/epidemiologia , Infecções Oportunistas/complicações , Infecções Oportunistas/mortalidade , Adulto Jovem
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