1
|
Smitherman EA, Chahine RA, Beukelman T, Lewandowski LB, Rahman AKMF, Wenderfer SE, Curtis JR, Hersh AO. Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care. Arthritis Care Res (Hoboken) 2023; 75:1553-1562. [PMID: 36775844 PMCID: PMC10500561 DOI: 10.1002/acr.25002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 07/14/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis. METHODS We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded. RESULTS We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers. CONCLUSION In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.
Collapse
|
2
|
Brunner HI, Vadhariya A, Dickson C, Crandall W, Kar-Chan Choong C, Birt JA, Ruperto N, Ramanan AV. Treatment patterns in paediatric and adult patients with SLE: a retrospective claims database study in the USA. Lupus Sci Med 2023; 10:e000817. [PMID: 37429670 DOI: 10.1136/lupus-2022-000817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 06/07/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To assess real-world treatment regimens and patterns in childhood-onset SLE (cSLE) and adult-onset SLE (aSLE) cohorts, including similarities in treatments, duration of use and adherence. METHODS This retrospective study utilised data from Merative L.P. MarketScan Research Databases (USA). Index date was the date of first SLE diagnosis (2010-2019). Patients aged <18 years (cSLE) and ≥18 years (aSLE) at index date with confirmed SLE diagnosis and ≥12 months continuous enrolment during pre-index and post-index periods were included. The cohorts were stratified based on the presence (existing) or absence (new) of pre-index SLE. Primary outcomes (post-index period) included treatment regimens (all patients), and adherence (proportion of days covered (PDC)) and discontinuation of therapies initiated within 90 days of diagnosis (new patients). Univariate comparisons between cSLE and aSLE cohorts were performed using Wilcoxon rank-sum and χ2 (or Fisher's exact) tests. RESULTS cSLE cohort included 1275 patients (mean age=14.1 years) and aSLE cohort included 66 326 patients (mean age=49.7 years). Antimalarials and glucocorticoids were commonly used among new (cSLE=64.4%/62.0%; aSLE=51.8%/49.7%) and existing (cSLE=68.6%/58.9%; aSLE=63.8%/51.3%) patients in both cohorts. Median oral glucocorticoid dose (prednisone equivalent) was higher in cSLE vs aSLE (new=22.1 vs 14.0 mg/day; existing=14.4 vs 12.3 mg/day; p<0.05). Mycophenolate mofetil use was higher in patients with cSLE vs aSLE (new=26.2% vs 5.8%; existing=37.6% vs 11.0%; p<0.0001). Compared with aSLE, more patients used combination therapies in cSLE (p<0.0001). Median PDC was higher in cSLE vs aSLE for antimalarials (0.9 vs 0.8; p<0.0001) and oral glucocorticoids (0.6 vs 0.3; p<0.0001). Treatment discontinuation was lower in cSLE vs aSLE for antimalarials (25.0% vs 33.1%; p<0.0001) and oral glucocorticoids (56.6% vs 71.2%; p<0.0001). CONCLUSIONS Management of cSLE and aSLE includes the same medication classes; differences include more intensive use of therapy in cSLE, warranting the need for approved safe medications for cSLE.
Collapse
Affiliation(s)
- Hermine I Brunner
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | | | | | | | | | - Julie A Birt
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, UOC Gaslini Trial Centre/Servizio di Sperimentazioni Cliniche Pediatriche, PRINTO, Genova, Italy
| | - Athimalaipet V Ramanan
- Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| |
Collapse
|
3
|
Cody EM, Wilson BE, Ogbu EA, Huggins JL, Chen C, Qiu T, Ting TV, Flores F, Huang B, Brunner HI. Usefulness of the lupus low disease activity state as a treatment target in childhood-onset SLE. Lupus Sci Med 2023; 10:e000884. [PMID: 37253553 PMCID: PMC10230998 DOI: 10.1136/lupus-2022-000884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 05/13/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Treat-to-target (T2T) strategies are advocated to improve prognosis in childhood-onset SLE (cSLE). Proposed T2T states include SLEDAI score of <4 (SLEDAI-LD), limited corticosteroid use (low-CS), and lupus low disease activity state (LLDAS). We sought to compare T2T states for their association with cSLE prognosis under consideration of relevant disease characteristics such as pre-existing damage, race and lupus nephritis (LN). METHODS Longitudinal data from 165 patients enrolled in the Cincinnati Lupus Registry were included. LN presence was based on renal biopsy, and patients were followed up until 18 years of age. RESULTS The 165 patients (LN: 45, white: 95) entered the registry within a median of 0 (IQR: 0-1) year post diagnosis and were followed up for a median of 4 (IQR: 2-5) years during which 80%, 92% and 94% achieved LLDAS, low-CS and SLEDAI-LD. Patients with LN were significantly less likely to achieve any T2T state (all p<0.03) and required a significantly longer time to reach them (all p<0.0001). Over the study period, patients maintained low-CS, SLEDAI-LD or LLDAS for a median of 76% (IQR: 48%-100%), 86% (IQR: 55%-100%) or 39% (IQR: 13%-64%) of their follow-up. Significant predictors of failure to maintain LLDAS included LN (p≤0.0062), pre-existing damage (p≤0.0271) and non-white race (p≤0.0013). There were 22%, 20% and 13% of patients who reached SLEDAI-LD, CS-low and LLDAS and nonetheless acquired new damage. Patients with LN had a higher risk of new damage than patients without LN even if achieving low-CS (p=0.009) or LLDAS (p=0.04). CONCLUSIONS Patients with LN and pre-existing damage are at higher risk of increased future damage acquisition, even if achieving a T2T state such as LLDAS. Among proposed common T2T states, the LLDAS is the hardest to achieve and maintain. The LLDAS may be considered the preferred T2T measure as it conveys the highest protection from acquiring additional disease damage.
Collapse
Affiliation(s)
- Ellen M Cody
- Pediatrics, Division of Nephrology, Hypertension and Pheresis, Washington University in St Louis, St Louis, Missouri, USA
| | - Bridget E Wilson
- Pediatrics, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| | - Ekemini A Ogbu
- Pediatrics, Division of Rheumatology, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
- Pediatrics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer L Huggins
- Pediatrics, Division of Rheumatology, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| | - Chen Chen
- Pediatrics, Division of Epidemiology & Biostatistics, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| | - Tingting Qiu
- Pediatrics, Division of Epidemiology & Biostatistics, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| | - Tracy V Ting
- Pediatrics, Division of Rheumatology, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| | - Francisco Flores
- Pediatrics, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| | - Bin Huang
- Pediatrics, Division of Epidemiology & Biostatistics, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| | - Hermine I Brunner
- Pediatrics, Division of Rheumatology, Cincinnati Children's Hospital Medical Center Burnet Campus, Cincinnati, Ohio, USA
| |
Collapse
|
4
|
Chang JC, Weiss PF, Xiao R, Atkinson MA, Wenderfer SE. Use of renin angiotensin aldosterone system inhibitors in children with lupus and time to glucocorticoid discontinuation. Kidney Int 2022; 102:395-404. [PMID: 35618096 PMCID: PMC9329244 DOI: 10.1016/j.kint.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/07/2022] [Accepted: 04/08/2022] [Indexed: 02/06/2023]
Abstract
There is little data to inform use of renin angiotensin aldosterone system (RAAS) inhibitors in pediatric patients with systemic lupus erythematosus (SLE). Here, we sought to characterize RAAS inhibitor use in pediatric SLE, and determine whether early RAAS inhibitor initiation among children with incident lupus nephritis is associated with decreased duration of chronic glucocorticoid exposure. A retrospective cohort study was performed of children (ages 5-18) with SLE and/or lupus nephritis in the Truven MarketScanΤΜ Medicaid and Commercial databases (2013-2018) and estimated RAAS inhibitor use. Among incident nephritis cases, we used competing risk hazard models with inverse probability of treatment weighting to estimate the association between RAAS inhibitor initiation less than 180 days after diagnosis and time to glucocorticoid discontinuation with kidney failure as a competing event. Among 592 children with nephritis and 1407 children with non-kidney SLE, 67% and 15% ever received RAAS inhibitors, respectively. Median duration of RAAS inhibitor use among 323 incident users was 14 and 9 months in children with and without nephritis, respectively. Medicaid enrollment was independently associated with greater likelihood of RAAS inhibitor use, irrespective of nephritis. Among 158 incident nephritis cases, early RAAS inhibitor initiation was significantly associated with a faster rate of glucocorticoid discontinuation (adjusted sub-distribution hazard ratio 1.81, 95% confidence interval [1.09 - 3.00]). Thus, early initiation of RAAS inhibitors may have a role in children newly diagnosed with lupus nephritis; not only those with refractory proteinuria after induction therapy. Hence, integrated health systems data could be leveraged to confirm these findings and optimize adjunctive therapies in pediatric lupus.
Collapse
Affiliation(s)
- Joyce C Chang
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia Research Institute, Philadelphia PA; Division of Immunology, Boston Children's Hospital and Harvard Medical School, Boston MA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.
| | - Pamela F Weiss
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia Research Institute, Philadelphia PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA; Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Scott E Wenderfer
- Pediatric Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston TX
| |
Collapse
|
5
|
Sun L, Shen Q, Gong Y, Li Y, Lv Q, Liu H, Zhao F, Yu H, Qiu L, Li X, He X, Chen Y, Xu Z, Xu H. Safety and efficacy of telitacicept in refractory childhood-onset systemic lupus erythematosus: A self-controlled before–after trial. Lupus 2022; 31:998-1006. [PMID: 35499216 DOI: 10.1177/09612033221097812] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To observe the efficacy and safety of telitacicept in refractory childhood-onset systemic lupus erythematosus (cSLE). Methods A self-controlled before–after trial. Children with active SLE, aged 5–18 years, who cannot tolerate side effects of glucocorticoid, were enrolled in our study. Patients received subcutaneous injection of telitacicept weekly based on the standard treatment. SLE responder index-4 (SRI-4) was assessed before the first administration and at least 4 weeks after the first administration. Results Among the 15 cases of refractory cSLE, three were males (20%) and 12 were females (80%). The median age and weight were 13 years old and 52 kg, respectively. The median duration of disease was 30 months. 5–26 weeks (80 or 160 mg per week) after administration of telitacicept, 66.7% ( n=10) reached SRI-4 response. 12 cases reduced their glucocorticoid intake from 40 mg/d to 17.5 mg/d. The urinary protein after treatment declined in 8 cases whose 24-h proteinuria was >0.5 g at baseline. The urinary protein in two of the eight cases turned negative and plasma albumin in five of the eight cases rose to normal. In addition, three of these eight cases demonstrated varying degrees of improvement in renal impairment, whose estimated glomerular filtration rate (eGFR, ml/min·1.73 m2) rose from 17.4 to 26.6, 40.7 to 48.2, and 63.2 to 146.0, respectively. There were mild to moderate adverse events after treatment. Conclusion Telitacicept combined with the standard treatment may significantly increase the SRI-4 response rate and reduce the glucocorticoid dosage in refractory cSLE, and also shown efficacy on lupus nephritis. The related adverse drug events were controllable.
Collapse
Affiliation(s)
- Li Sun
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Yinv Gong
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Yifan Li
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Qianying Lv
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Haimei Liu
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| | - Fei Zhao
- Department of Nephrology, Children’s Hospital of Nanjing Medical University, Jiangsu, China
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Jiangsu, China
| | - Lingzhi Qiu
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Jiangsu, China
| | - Xiaozhong Li
- Department of Nephrology and Rheumatology, Children’s Hospital of Soochow University, Jiangsu, China
| | - Xiaoliang He
- Department of Rheumatology, Children’s Hospital of Fudan University Anhui Hospital, Anhui, China
| | - Yuqing Chen
- Department of Rheumatology, Children’s Hospital of Fudan University Anhui Hospital, Anhui, China
| | - Zhiquan Xu
- Department of Nephrology and Rheumatology, Children’s Hospital of Fudan University at Hainan, Hainan, China
| | - Hong Xu
- Department of Rheumatology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
- Department of Nephrology, Children’s Hospital of Fudan University, National Children’s Medical Center, Shanghai, China
| |
Collapse
|
6
|
Chang JC, Sears C, Torres V, Son MB. Racial Disparities in Renal Outcomes over Time among Hospitalized Children with Systemic Lupus Erythematosus. Arthritis Rheumatol 2022; 74:1430-1439. [PMID: 35384383 PMCID: PMC9339464 DOI: 10.1002/art.42127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/19/2022] [Accepted: 03/22/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Racial and ethnic minority groups have excess morbidity related to renal disease in pediatric-onset systemic lupus erythematosus (SLE). We evaluated temporal trends in renal outcomes and racial disparities among hospitalized children with SLE over 14 years. METHODS We identified patients ≤21 years-old with discharge diagnoses of SLE in the Pediatric Health Information System® inpatient database (2006-2019). Adverse renal outcomes included end-stage renal disease (ESRD), dialysis, or transplant, analyzed as a composite and separately. We estimated the odds of adverse renal outcomes at any hospitalization, or the first occurrence of an adverse renal outcome, adjusted for calendar period, patient characteristics, and clustering by hospital. We tested whether racial disparities differed by calendar period. RESULTS There were 20,893 admissions for 7,434 SLE patients, of which 32%, 16%, 12% and 8% were Black, Hispanic White, Hispanic Other and Asian, respectively. Proportions of admissions with adverse renal outcomes decreased over time (p<0.01). Black children remained at highest risk of adverse renal outcomes at any admission (OR 2.5, 95% CI [1.8-3.5] vs. non-Hispanic White). Black and Asian children remained at higher risk of incident adverse renal outcomes, driven by ESRD among Black children (OR 1.6 [1.2-2.1]) and dialysis among Asians (OR 1.7 [1.1-2.7]). Relative disparities did not change significantly over time. CONCLUSION Significant reductions in ESRD and dialysis occurred over time for children with SLE across all racial and ethnic groups. The lack of corresponding reductions in racial disparities highlights the need for targeted interventions to achieve greater treatment benefit among higher risk groups.
Collapse
Affiliation(s)
- Joyce C Chang
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute.,Division of Immunology, Boston Children's Hospital and Harvard Medical School.,Division of Rheumatology, Children's Hospital of Philadelphia
| | - Cora Sears
- Division of Rheumatology, Children's Hospital of Philadelphia
| | | | - Mary Beth Son
- Division of Immunology, Boston Children's Hospital and Harvard Medical School
| |
Collapse
|
7
|
Vara E, Gilbert M, Ruth NM. Health disparities in outcomes of pediatric systemic lupus erythematosus. Front Pediatr 2022; 10:879208. [PMID: 36313870 PMCID: PMC9614219 DOI: 10.3389/fped.2022.879208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Healthcare disparities exist throughout the United States, and disparities in healthcare delivery are responsible for a substantial portion of preventable morbidity and mortality. SLE disproportionately affects racial and ethnic minoritized groups, including Blacks, Hispanics, and Asians/Pacific Islanders. Specifically, Black females have a 3 to 4-fold increased risk of developing SLE than White females. Population studies funded through the Centers for Disease Control have examined variations in disease outcomes among the different populations around the United States. For example, studies have shown that lupus nephritis, anti-phospholipid syndrome, and thrombocytopenia are more likely to affect racial and ethnic minorities than Whites. In addition, the Center for Disease Control WONDER (Wide-ranging Online Data for Epidemiologic Research) database found SLE was the seventh leading cause of death for all women aged 15-25 years and the fifth leading cause of death for African American and Hispanic females. From these studies, we know SLE primarily affects racial and ethnic minorities, but we do not know why these groups are at increased risk of developing the disease or have worse outcomes. By examining the underlying mechanisms of health disparities within our patient populations and mitigation strategies, we will further understand and provide better treatment for our patients. This review will discuss current research related to health disparities and health outcomes in childhood-onset SLE (cSLE).
Collapse
Affiliation(s)
- Emily Vara
- Medical University of South Carolina, Charleston, SC, United States
| | - Mileka Gilbert
- Medical University of South Carolina, Charleston, SC, United States
| | - Natasha M Ruth
- Medical University of South Carolina, Charleston, SC, United States
| |
Collapse
|
8
|
Wahadat MJ, van den Berg L, Timmermans D, van Rijswijk K, van Dijk-Hummelman A, Bakx S, Verkaaik M, Versnel MA, Kamphuis S. LLDAS is an attainable treat-to-target goal in childhood-onset SLE. Lupus Sci Med 2021; 8:e000571. [PMID: 34969874 PMCID: PMC8719245 DOI: 10.1136/lupus-2021-000571] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/12/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To study whether clinical remission (CR) and Low Lupus Disease Activity State (LLDAS) are achievable goals in childhood-onset SLE. METHODS Data on medication use and disease activity were prospectively collected. LLDAS was defined as Safety of Estrogen in Lupus Erythematosus National Assesment-SLE disease Activity Index (SELENA-SLEDAI) ≤4 with zero scores for renal, Central Nervous System (CNS), serositis, vasculitis and constitutional components, no increase in any SLEDAI component since the previous visit, PGA ≤1, and prednisone dose ≤7.5 mg/day. CR on treatment (Tx) was defined as a Physician Global Assessment <0.5, SELENA-SLEDAI=0, with prednisone ≤5 mg/day and maintenance treatment with immunosuppressives. CR off Tx was the same but without prednisone or other immunosuppressive usage. RESULTS 51 patients (700 visits) were included. Within 3 months after diagnosis, 94.1% of children were treated with hydroxychloroquine and 60.8% with prednisone. Prednisone dosage decreased from a median of 0.74 mg/kg/day at diagnosis to 0.44 mg/kg/day at 3 months and 0.16 mg/kg/day at 6 months after diagnosis. Use of mycophenolate mofetil increased from 25.5% to 56.9% within 6 months after diagnosis. All children achieved LLDAS (median 186 days) and 72.5% remained in LLDAS >50% of time. 52.9% children achieved CR on Tx, and only 21.6% children achieved CR off Tx. CONCLUSIONS LLDAS is an attainable treat-to-target goal in contrast to CR on and off Tx. Even more, LLDAS can be reached with limited use of corticosteroids with early introduction of immunosuppressives.
Collapse
Affiliation(s)
- Mohamed Javad Wahadat
- Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lotte van den Berg
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Demi Timmermans
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Kevin van Rijswijk
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Annette van Dijk-Hummelman
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Susan Bakx
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marleen Verkaaik
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marjan A Versnel
- Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Sylvia Kamphuis
- Department of Paediatric Rheumatology, Erasmus MC Sophia Children's Hospital, Rotterdam, The Netherlands
| |
Collapse
|
9
|
Smitherman EA, Goh I, Pooni R, Vora SS, Yildirim-Toruner C, von Scheven E. Implementation Science in Pediatric Rheumatology: A Path to Health Equity. Rheum Dis Clin North Am 2021; 48:331-342. [PMID: 34798956 DOI: 10.1016/j.rdc.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Implementation science is the study of processes that promote reliable uptake of evidence-based practices into clinical care. The integration of implementation science and health disparities research approaches has been proposed as a method to reduce health inequity through detection, understanding, and implementation of health equity-focused interventions. In this review, we provide an argument for the study of implementation science in pediatric rheumatology in light of previously observed health disparities, present a framework for the study of health equity and implementation science in pediatric rheumatology, and propose next steps to accelerate action.
Collapse
Affiliation(s)
- Emily A Smitherman
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, 1601 4th Avenue South, Park Place North Suite G10, Birmingham, AL 35233, USA.
| | - Ingrid Goh
- Division of Rheumatology, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M5G 0A4, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Rajdeep Pooni
- Division of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Stanford Children's Health, 700 Welch Road, Suite 301, Palo Alto, CA 94304, USA
| | - Sheetal S Vora
- Department of Pediatrics, Atrium Health Levine Children's Hospital, 1000 Blythe Boulevard, 4th Floor, Charlotte, NC 28203, USA
| | - Cagri Yildirim-Toruner
- Department of Pediatrics, Baylor College of Medicine, 6701 Fannin Street, 11th Floor, Houston, TX 77030, USA
| | - Emily von Scheven
- Division of Pediatric Rheumatology, University of California San Francisco, 550 16th Street, 5th Floor, #5453, San Francisco, CA, USA
| |
Collapse
|
10
|
Abstract
Cardiovascular disease risk is evident during childhood for patients with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and juvenile idiopathic arthritis. The American Heart Association defines cardiovascular health as a positive health construct reflecting the sum of protective factors against cardiovascular disease. Disease-related factors such as chronic inflammation and endothelial dysfunction increase cardiovascular disease risk directly and through bidirectional relationships with poor cardiovascular health factors. Pharmacologic and nonpharmacologic interventions to improve cardiovascular health and long-term cardiovascular outcomes in children with rheumatic disease are needed.
Collapse
|
11
|
Burnham JM, Cecere L, Ukaigwe J, Knight A, Peterson R, Chang JC. Factors Associated With Variation in Pediatric Systemic Lupus Erythematosus Care Delivery. ACR Open Rheumatol 2021; 3:708-714. [PMID: 34551217 PMCID: PMC8516107 DOI: 10.1002/acr2.11314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Patients with pediatric systemic lupus erythematosus (pSLE) and mixed connective tissue disease (MCTD) receive only a fraction of recommended care. Using published quality indicators and guidelines, we developed a 13‐item pediatric lupus care index (p‐LuCI) to quantify the proportion of recommended clinical evaluations and comorbidity prevention interventions completed and the timeliness of follow‐up. Our objective was to assess baseline index performance and identify sources of p‐LuCI variation. Methods We performed a cross‐sectional study in patients with pSLE or MCTD and analyzed the performance of individual p‐LuCI process metrics and calculated the overall p‐LuCI score. We identified factors associated with the p‐LuCI using multivariable linear regression with clustering by provider. Results For 110 patients (99 with pSLE and 11 with MCTD), the median p‐LuCI was 65.2% (interquartile range: 9.1‐92.3%). Component performance ranged from 27.3% (on‐time scheduling) to 95.4% (steroid‐sparing treatment). Patients with p‐LuCI scores above the median had higher scores across all 13 components. Higher p‐LuCI scores were independently associated with disease‐modifying antirheumatic drug use (β = 14.3 [95% confidence interval (CI), 1.5‐27.2]), nephritis (β = 10.4 [95% CI, 5.1‐15.8]), higher provider pSLE/MCTD volume (β = 3.1 [95% CI, 1.9‐4.2] per patient), assignment to rheumatology fellow trainee (β = 36.3 [95% CI, 17.3‐55.2]), and disease duration of less than 1 year (β = 12.6 [95% CI, 0.7‐24.5]). Differences by race, ethnicity, and/or insurance were not observed. Conclusion Using an index of recommended pSLE care metrics, we identified significant variation in performance by disease, treatment, and provider characteristics. The p‐LuCI may be useful to assess care quality at the patient, provider, and practice levels and to identify areas in need of greater standardization.
Collapse
Affiliation(s)
- Jon M Burnham
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lynsey Cecere
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joy Ukaigwe
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrea Knight
- Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Joyce C Chang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Trindade VC, Carneiro-Sampaio M, Bonfa E, Silva CA. An Update on the Management of Childhood-Onset Systemic Lupus Erythematosus. Paediatr Drugs 2021; 23:331-347. [PMID: 34244988 PMCID: PMC8270778 DOI: 10.1007/s40272-021-00457-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 02/06/2023]
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) is a prototype of a multisystemic, inflammatory, heterogeneous autoimmune condition. This disease is characterized by simultaneous or sequential organ and system involvement, with unpredictable flare and high levels of morbidity and mortality. Racial/ethnic background, socioeconomic status, cost of medications, difficulty accessing health care, and poor adherence seem to impact lupus outcomes and treatment response. In this article, the management of cSLE patients is updated. Regarding pathogenesis, a number of potential targets for drugs have been studied. However, most treatments in pediatric patients are off-label drugs with recommendations based on inadequately powered studies, therapeutic consensus guidelines, or case series. Management practices for cSLE patients include evaluations of disease activity and cumulative damage scores, routine non-live vaccinations, physical activity, and addressing mental health issues. Antimalarials and glucocorticoids are still the most common drugs used to treat cSLE, and hydroxychloroquine is recommended for nearly all cSLE patients. Disease-modifying antirheumatic drugs (DMARDs) should be standardized for each patient, based on disease flare and cSLE severity. Mycophenolate mofetil or intravenous cyclophosphamide is suggested as induction therapy for lupus nephritis classes III and IV. Calcineurin inhibitors (cyclosporine, tacrolimus, voclosporin) appear to be another good option for cSLE patients with lupus nephritis. Regarding B-cell-targeting biologic agents, rituximab may be used for refractory lupus nephritis patients in combination with another DMARD, and belimumab was recently approved by the US Food and Drug Administration for cSLE treatment in children aged > 5 years. New therapies targeting CD20, such as atacicept and telitacicept, seem to be promising drugs for SLE patients. Anti-interferon therapies (sifalimumab and anifrolumab) have shown beneficial results in phase II randomized control trials in adult SLE patients, as have some Janus kinase inhibitors, and these could be alternative treatments for pediatric patients with severe interferon-mediated inflammatory disease in the future. In addition, strict control of proteinuria and blood pressure is required in cSLE, especially with angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use.
Collapse
Affiliation(s)
- Vitor Cavalcanti Trindade
- Children and Adolescent Institute, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Magda Carneiro-Sampaio
- Children and Adolescent Institute, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil
| | - Eloisa Bonfa
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Clovis Artur Silva
- Children and Adolescent Institute, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, Brazil.
- Rheumatology Division, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 647, Cerqueira César, São Paulo, SP, 05403-000, Brazil.
| |
Collapse
|
13
|
|
14
|
Luo KL, Yang YH, Lin YT, Hu YC, Yu HH, Wang LC, Chiang BL, Lee JH. Differential parameters between activity flare and acute infection in pediatric patients with systemic lupus erythematosus. Sci Rep 2020; 10:19913. [PMID: 33199770 PMCID: PMC7670442 DOI: 10.1038/s41598-020-76789-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/02/2020] [Indexed: 12/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) patients are vulnerable to infections. We aim to explore the approach to differentiate active infection from disease activity in pediatric SLE patients. Fifty pediatric SLE patients presenting with 185 clinical visits were collected. The associations between both clinical and laboratory parameters and the outcome groups were analyzed using generalized estimating equations (GEEs). These 185 visits were divided into 4 outcome groups: infected-active (n = 102), infected-inactive (n = 11), noninfected-active (n = 59), and noninfected-inactive (n = 13) visits. Multivariate GEE (generalized estimating equation) analysis showed that SDI, SLEDAI-2K, neutrophil‐to‐lymphocyte ratio (NLR), hemoglobin, platelet, RDW-to-platelet ratio (RPR), and C3 are predictive of flare (combined calculated AUC of 0.8964 and with sensitivity of 82.2% and specificity of 90.9%). Multivariate GEE analysis showed that SDI, fever temperature, CRP, procalcitonin (PCT), lymphocyte percentage, NLR, hemoglobin, and renal score in SLEDAI-2k are predictive of infection (combined calculated AUC of 0.7886 and with sensitivity of 63.5% and specificity of 89.2%). We can simultaneously predict 4 different outcome with accuracy of 70.13% for infected-active group, 10% for infected-inactive group, 59.57% for noninfected-active group, and 84.62% for noninfected-inactive group, respectively. Combination of parameters from four different domains simultaneously, including inflammation (CRP, ESR, PCT), hematology (Lymphocyte percentage, NLR, PLR), complement (C3, C4), and clinical status (SLEDAI, SDI) is objective and effective to differentiate flares from infections in pediatric SLE patients.
Collapse
Affiliation(s)
- Kai-Ling Luo
- Department of Pediatrics, Cathay General Hospital, Taipei, 10630, Taiwan, ROC
| | - Yao-Hsu Yang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Yu-Tsan Lin
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Ya-Chiao Hu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Hsin-Hui Yu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Li-Chieh Wang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, 10002, Taiwan, ROC
| | - Jyh-Hong Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, 8 Chung-Shan South Road, Taipei, 10002, Taiwan, ROC.
| |
Collapse
|
15
|
Arora S, Yazdany J. Use of Quality Measures to Identify Disparities in Health Care for Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2020; 46:623-638. [PMID: 32981640 DOI: 10.1016/j.rdc.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Assessment of quality of care for people with systemic lupus erythematosus (SLE) provides opportunities to identify gaps in health care and address disparities. Poor access to specialty care has been shown to negatively impact care in SLE and is associated with poor disease outcomes. Racial/ethnic minorities and those with low socioeconomic status are at higher risk for poor access and lower quality of care. Quality measures evaluating processes of care have shown significant deficiencies in care of SLE patients across studies. High SLE patient volume correlates with better quality of care for providers in hospital and ambulatory settings.
Collapse
Affiliation(s)
- Shilpa Arora
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA
| | - Jinoos Yazdany
- Division of Rheumatology, University of California, San Francisco, 1001 Potrero Avenue, Suite 3300, San Francisco, CA 94110, USA.
| |
Collapse
|
16
|
Trachana M, Pratsidou-Gertsi P, Kanakoudi-Tsakalidou F, Tzimouli V, Printza N, Papachristou F. Impact of the longitudinal quantitative assessment of juvenile systemic lupus erythematosus severity on the disease outcome. Clin Rheumatol 2020; 40:675-682. [PMID: 32638251 DOI: 10.1007/s10067-020-05252-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study on juvenile SLE patients aimed to evaluate retrospectively the impact of a tertiary center's management policy of the disease severity on its long-term progression and cumulative damage development as well as provision of quality-driven medical care (QmC). METHODS Disease activity was assessed by the Physician Global Assessment and SLEDAI-2K, flares by SELENA/SLEDAI, and damage by the pediatric SLICC/DI at diagnosis, 6 months post-diagnosis, and annually thereafter. At the same time, QmC was evaluated by relevant indices and quality of life was captured by the Greek version of the General Health Questionnaire only at the last visit. RESULTS A total of 35 patients (25/35 females) aged at diagnosis 5.5-15.16 years (median 11.83) with a median lag time to diagnosis 1.8 months had a follow-up of 5 (35/35) and 10 years (13/35), respectively. The predominant baseline manifestations were consistent with those previously reported. Out of 35 patients, 24 (68.5%) were clinically inactive at year 5, and 5/13 (38%) at year 10. All patients received immunosuppressives and 7/35 biologics in addition. At the end of their follow-up, damage was found in 9/35 patients, but none of them had a neuropsychiatric disorder. Over the study, 28/35 patients were compliant with the QmC recommendations. CONCLUSIONS An early diagnosis combined with a longitudinal quantitative assessment of the disease activity and severity contributes to the continuous evaluation of the disease state. They are the key determinants for the selection of an early, targeted, and personalized management; they restrict the cumulative damage development and contribute to an optimal outcome. Key Points • Juvenile SLE has a heavier introductory profile than in adults and an unpredictable trajectory. • The application of contemporary metric tools for assessing the disease state leads to an objective assessment and regimen selection. • An early diagnosis combined with longitudinal quantitative assessment is a key determinant for an optimal management and a minimal damage development.
Collapse
Affiliation(s)
- Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, 1st Dept. of Pediatrics, Hippokration General Hospital Aristotle University, 10, 49, Konstantinoupoleos Street, GR54642, Thessaloniki, Greece.
| | - Polyxeni Pratsidou-Gertsi
- Pediatric Immunology and Rheumatology Referral Center, 1st Dept. of Pediatrics, Hippokration General Hospital Aristotle University, 10, 49, Konstantinoupoleos Street, GR54642, Thessaloniki, Greece
| | - Florence Kanakoudi-Tsakalidou
- Pediatric Immunology and Rheumatology Referral Center, 1st Dept. of Pediatrics, Hippokration General Hospital Aristotle University, 10, 49, Konstantinoupoleos Street, GR54642, Thessaloniki, Greece
| | - Vasiliki Tzimouli
- Pediatric Immunology and Rheumatology Referral Center, 1st Dept. of Pediatrics, Hippokration General Hospital Aristotle University, 10, 49, Konstantinoupoleos Street, GR54642, Thessaloniki, Greece
| | - Nikoleta Printza
- Pediatric Nephrology Unit, 1st Dept. of Pediatrics, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Fotis Papachristou
- Pediatric Nephrology Unit, 1st Dept. of Pediatrics, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| |
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW Provide an update of studies published in last 2 years on the outcomes and therapies in childhood-onset systemic lupus erythematous (cSLE). RECENT FINDINGS Additional evidence has been provided about the benefits of universal hydroxychloroquine in SLE patients, although antimalarial maculopathy may be more prevalent than previously thought. Recent studies support lower glucocorticoid doses than used in the past may provide comparable therapeutic benefits, and cSLE patients can mount adequate immunogenic response and sustain long-term seroprotective titers when vaccinated. Long-term studies of adults with cSLE confirmed that damage accrual increases with disease duration. Cardiovascular disease, renal transplants, replacement arthroplasties, and myocardial infarctions occur between 20 and 40 years of age. Higher prednisone doses predicted higher damage trajectory and antimalarial exposure was protective. There were no prospective clinical trials published in pediatric patients with cSLE, but positive results from phase II trials with bariticinib and ustekinumab in adult SLE may raise the expectation that these drugs could be beneficial when used in cSLE. SUMMARY The dire need for more clinical trials and licensed medications for cSLE persist as well as decreasing damage accrual.
Collapse
|
18
|
Galindo-Zavala R, Bou-Torrent R, Magallares-López B, Mir-Perelló C, Palmou-Fontana N, Sevilla-Pérez B, Medrano-San Ildefonso M, González-Fernández MI, Román-Pascual A, Alcañiz-Rodríguez P, Nieto-Gonzalez JC, López-Corbeto M, Graña-Gil J. Expert panel consensus recommendations for diagnosis and treatment of secondary osteoporosis in children. Pediatr Rheumatol Online J 2020; 18:20. [PMID: 32093703 PMCID: PMC7041118 DOI: 10.1186/s12969-020-0411-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/03/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Osteoporosis incidence in children is increasing due to the increased survival rate of patients suffering from chronic diseases and the increased use of drugs that can damage bones. Recent changes made to the definition of childhood osteoporosis, along with the lack of guidelines or national consensuses regarding its diagnosis and treatment, have resulted in a wide variability in the approaches used to treat this disease. For these reasons, the Osteogenesis Imperfecta and Childhood Osteoporosis Working Group of the Spanish Society of Pediatric Rheumatology has sounded the need for developing guidelines to standardize clinical practice with regard to this pathology. METHODS An expert panel comprised of 6 pediatricians and 5 rheumatologists carried out a qualitative literature review and provided recommendations based on evidence, when that was available, or on their own experience. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A Delphi survey was conducted for those recommendations with an evidence level of IV or V. This survey was sent to all members of the SERPE. All recommendations that had a level of agreement higher or equal to 70% were included. RESULTS Fifty-one recommendations, categorized into eight sections, were obtained. Twenty-four of them presented an evidence level 4 or 5, and therefore a Delphi survey was conducted. This was submitted electronically and received a response rate of 40%. All recommendations submitted to the Delphi round obtained a level of agreement of 70% or higher and were therefore accepted. CONCLUSION In summary, we present herein guidelines for the prevention, diagnosis and treatment of secondary childhood osteoporosis based on the available evidence and expert clinical experience. We believe it can serve as a useful tool that will contribute to the standardization of clinical practice for this pathology. Prophylactic measures, early diagnosis and a proper therapeutic approach are essential to improving bone health, not only in children and adolescents, but also in the adults they will become in the future.
Collapse
Affiliation(s)
- Rocío Galindo-Zavala
- UGC Pediatría. Sección Reumatología Pediátrica, Hospital Regional Universitario de Málaga, Málaga, Spain.
| | - Rosa Bou-Torrent
- 0000 0001 0663 8628grid.411160.3Unidad de Reumatología Pediátrica, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Berta Magallares-López
- 0000 0004 1768 8905grid.413396.aServicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Concepción Mir-Perelló
- 0000 0004 1796 5984grid.411164.7Unidad de Pediatría, Sección Reumatología Pediátrica, Hospital Universitari Son Espases, Palma de Mallorca, Spain
| | - Natalia Palmou-Fontana
- 0000 0001 0627 4262grid.411325.0Unidad de Reumatología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Belén Sevilla-Pérez
- UGC Pediatría, Sección Reumatología Pediátrica, Hospital Campus de la Salud, Granada, Spain
| | | | - Mª. Isabel González-Fernández
- 0000 0001 0360 9602grid.84393.35Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital La Fe, Valencia, Spain
| | | | - Paula Alcañiz-Rodríguez
- Unidad de Pediatría, Sección de Reumatología Pediátrica, Hospital Virgen de la Arriaxaca, Murcia, Spain
| | - Juan Carlos Nieto-Gonzalez
- 0000 0001 0277 7938grid.410526.4Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Mireia López-Corbeto
- 0000 0001 0675 8654grid.411083.fServicio de Reumatología Hospital Vall d’Hebron, Barcelona, Spain
| | - Jenaro Graña-Gil
- 0000 0004 1771 0279grid.411066.4Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain ,Osteogenesis Imperfecta and Secondary Osteoporosis Working Group from the Spanish Pediatric Rheumatology Society, Madrid, Spain
| |
Collapse
|
19
|
Sivaraman V, Wise KA, Cotton W, Barbar-Smiley F, AlAhmed O, MacDonald D, Lemle S, Yildirim-Toruner C, Ardoin SP, Ardura MI. Previsit Planning Improves Pneumococcal Vaccination Rates in Childhood-Onset SLE. Pediatrics 2020; 145:peds.2018-3141. [PMID: 31879277 DOI: 10.1542/peds.2018-3141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Childhood-onset systemic lupus erythematosus (c-SLE) is a complex autoimmune disease that requires systemic immunosuppressive therapy. Infections are the second leading cause of death in these patients, with invasive pneumococcal infections being a major preventable cause of morbidity and mortality. Pneumococcal vaccination is recommended in this population; however, vaccination rates remain low. METHODS The plan-do-study-act method of quality improvement was applied. We calculated baseline vaccination rates for pneumococcal conjugate and pneumococcal polysaccharide vaccines in patients with c-SLE in the rheumatology clinic from January 2015 to August 2016. We developed an age-based algorithm to simplify the vaccination guidelines. The clinical pharmacist and nurses performed weekly previsit planning to update vaccine records, make targeted recommendations, and ensure vaccine availability. The primary outcome measure was the percentage patients with of c-SLE seen per month who had received age-appropriate pneumococcal vaccination. RESULTS The percentage of children receiving at least 1 pneumococcal vaccine increased from 24.9% to 92.7% by 12 months. By 18 months, the compliance rate with both pneumococcal vaccines increased from 2.5% to 87.3%, with sustained results. No serious adverse events or disease flares were reported. CONCLUSIONS By identifying the major barriers to pneumococcal vaccination in our population with c-SLE, we significantly improved vaccination rates while decreasing time burden on providers. We attribute our success to a team-based quality improvement approach and plan to implement alerts in the electronic health record to streamline the process.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Monica I Ardura
- Infectious Diseases and Host Defense, Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, Ohio
| |
Collapse
|
20
|
Smith EMD, Lythgoe H, Midgley A, Beresford MW, Hedrich CM. Juvenile-onset systemic lupus erythematosus: Update on clinical presentation, pathophysiology and treatment options. Clin Immunol 2019; 209:108274. [PMID: 31678365 DOI: 10.1016/j.clim.2019.108274] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/12/2019] [Accepted: 10/13/2019] [Indexed: 12/25/2022]
Abstract
Juvenile-onset systemic lupus erythematosus (jSLE) accounts for up to 20% of all SLE patients. Key differences between juvenile- and adult-onset (aSLE) disease include higher disease activity, earlier development of damage, and increased use of immunosuppressive treatment in jSLE suggesting (at least partial) infectivity secondary to variable pathomechanisms. While the exact pathophysiology of jSLE remains unclear, genetic factors, immune complex deposition, complement activation, hormonal factors and immune cell dysregulation are involved to variable extents, promising future patient stratification based on immune phenotypes. Though less effective and potentially toxic, jSLE patients are treated based upon evidence from studies in aSLE cohorts. Here, age-specific clinical features of jSLE, underlying pathomechanisms, treatment options and disease outcomes will be addressed. Future directions to improve the care of jSLE patients, including implementation of the Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) recommendations, biomarkers, treat to target and personalized medicine approaches are discussed.
Collapse
Affiliation(s)
- Eve Mary Dorothy Smith
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
| | - Hanna Lythgoe
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Angela Midgley
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK
| | - Michael William Beresford
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Christian Michael Hedrich
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
| |
Collapse
|
21
|
Smitherman EA, Huang B, Furnier A, Taylor J, Burns MB, Brunner HI, Morgan EM. Quality of Care in Childhood-onset Systemic Lupus Erythematosus: Report of an Intervention to Improve Cardiovascular and Bone Health Screening. J Rheumatol 2019; 47:1506-1513. [PMID: 31474591 DOI: 10.3899/jrheum.190295] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Initial benchmarking of childhood-onset systemic lupus erythematosus (cSLE) quality indicators revealed suboptimal performance across multiple centers. Our aim was to improve cardiovascular and bone health screenings at a tertiary treatment center for cSLE. This included annual measurements of vitamin D, lipid profiles, and bone mineral density through dual-energy x-ray absorptiometry (DXA). METHODS Quality improvement methodology was applied to design and implement a standardized previsit planning process to electronically entered and saved orders for needed screenings prior to a scheduled clinic visit. Process outcomes were measured using statistical process control charts. Univariate analyses were completed to assess patient-level factors. RESULTS During the study, 123 patients with cSLE participated across 619 clinic visits. The percentage of patients with completed screenings improved from 54% to 92% for annual vitamin D, 55% to 84% for annual lipid profiles, and 57% to 78% for DXA, which was sustained for more than 1 year. Providers responded to a majority of abnormal results, and improvement in the average vitamin D level was observed over time. Higher levels of disease activity, damage, number of clinic visits, and screenings completed at baseline were observed in patients with all screenings completed at the end of the intervention. CONCLUSION Implementation of elements of the chronic illness care model for cSLE management improved performance of cardiovascular and bone health screenings, a step toward preventing longterm morbidity in cSLE. Our study also suggests that more patient interaction with the healthcare system may promote successful completion of health maintenance screenings.
Collapse
Affiliation(s)
- Emily A Smitherman
- E.A. Smitherman, MD, MSCTR, Assistant Professor, Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama;
| | - Bin Huang
- B. Huang, PhD, Professor, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati
| | - Adam Furnier
- A. Furnier, BS, [Q.swash]uality Impro[v.alt]ement Consultant, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Janalee Taylor
- J. Taylor, MSN, APRN, CNP, M.B. Burns, RN, CPN, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Mary Beth Burns
- J. Taylor, MSN, APRN, CNP, M.B. Burns, RN, CPN, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati
| | - Hermine I Brunner
- H.I. Brunner, MD, MSc, MBA, Professor, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati
| | - Esi M Morgan
- E.M. Morgan, MD, MSCE, Associate Professor, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
22
|
Deng J, Chalhoub NE, Sherwin CM, Li C, Brunner HI. Glucocorticoids pharmacology and their application in the treatment of childhood-onset systemic lupus erythematosus. Semin Arthritis Rheum 2019; 49:251-259. [PMID: 30987856 DOI: 10.1016/j.semarthrit.2019.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/26/2019] [Accepted: 03/14/2019] [Indexed: 12/17/2022]
Abstract
Glucocorticoids are potent anti-inflammatory and immunosuppressant medications and remain the mainstay of systemic lupus erythematosus (SLE) therapy. The potency of a specific glucocorticoid, i.e., the dose of glucocorticoid that is required to produce a specific effect, is dependent on its pharmacokinetic (PK) and pharmacodynamic (PD) properties. In this review, we summarize the PK/PD properties of commonly used glucocorticoids in an attempt to better delineate their role in the management of children with childhood-onset SLE (cSLE). We also address glucocorticoid side effects as these play a major role when deciding on the dose, frequency, and duration of use. A better understanding of the pharmacology of glucocorticoids appears useful to achieve improved outcomes in the management of cSLE.
Collapse
Affiliation(s)
- Jianghong Deng
- Department of Rheumatology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China; Division of Rheumatology, Cincinnati Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Nathalie E Chalhoub
- Division of Immunology, Allergy, and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Catherine M Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Caifeng Li
- Department of Rheumatology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, No. 56 Nanlishi Road, Xicheng District, Beijing 100045, China.
| | - Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
| |
Collapse
|
23
|
Gorelik M, Elizalde A, Wong Williams K, Gonzalez E, Cole JL. Immunogenicity of sequential 13-valent conjugated and 23-valent unconjugated pneumococcal vaccines in a population of children with lupus. Lupus 2018; 27:2228-2235. [PMID: 30380992 DOI: 10.1177/0961203318808589] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pneumococcal vaccination is recommended as a quality indicator for management of children with systemic lupus erythematosus. Literature on the immunogenicity of pneumococcal vaccines (PCVs) in children is scant. We sought to prospectively evaluate via an observational study, the immunogenicity to sequential children with lupus. Out of a cohort of 26 patients, approximately 65% achieved > 70% vaccinated serotype antibody levels of > 1.3 mcg/dL following PCV13, and of 22 patients followed through PPSV23 vaccination, 59% achieved the same. Patients with rituximab exposure in the 6 months prior to a vaccination were more likely to not achieve protective serotype levels ( p < 0.01 for PCV13, trend p = 0.07 for PPSV23). Three of 22 patients with no apparent risk factors did not achieve protective serotype levels. Non-responders to PCV13 generally did not respond to PPSV23. Retrospective healthy controls achieved 100% protective levels in response to PPSV23 vaccination, with 95% of serotypes being > 1.3 mcg/dL. Thus, sequential 13- and 23-valent pneumococcal vaccines achieve protective status for approximately two thirds of pediatric lupus patients in our population. Lack of response to vaccine may be secondary to induced or inherent functional impairments in the patient.
Collapse
Affiliation(s)
- M Gorelik
- 1 Division of Pediatric Allergy, Immunology and Rheumatology, Children's Hospital of San Antonio/Baylor College of Medicine, San Antonio, TX, USA
| | - A Elizalde
- 1 Division of Pediatric Allergy, Immunology and Rheumatology, Children's Hospital of San Antonio/Baylor College of Medicine, San Antonio, TX, USA
| | - K Wong Williams
- 2 Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - E Gonzalez
- 1 Division of Pediatric Allergy, Immunology and Rheumatology, Children's Hospital of San Antonio/Baylor College of Medicine, San Antonio, TX, USA
| | - J L Cole
- 1 Division of Pediatric Allergy, Immunology and Rheumatology, Children's Hospital of San Antonio/Baylor College of Medicine, San Antonio, TX, USA
| |
Collapse
|
24
|
Brunner HI, Martini A, Lovell DJ, Ruperto N. Clinical trials in children and adolescents with systemic lupus erythematosus: methodological aspects, regulatory landscape and future opportunities. Ann Rheum Dis 2018; 78:162-170. [PMID: 30232192 DOI: 10.1136/annrheumdis-2018-213198] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/10/2018] [Accepted: 08/11/2018] [Indexed: 11/04/2022]
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) is rare in many regions of the world, including Europe. Access to approved medications for cSLE is currently limited, among others, due to a lack of high-quality evidence from clinical trials. The objectives of the study were to evaluate the current regulatory framework regarding medication approvals, delineate barriers to clinical trial conduct, and strategies to improve access to new medications for cSLE. Relevant methodological and regulatory aspects, epidemiological data, study designs and outcome measures are reviewed, and the results of a survey among Paediatric Rheumatology International Trials Organisation/Pediatric Rheumatology Collaborative Study Group investigators are presented. Laws and regulations in the USA and Europe necessitate that novel medicines are studied in paediatric populations, if similar or the same diseases in adults have been found to benefit from them. Regulatory agencies consider cSLE the paediatric form of SLE in adults. For medicines that have been found safe and effective in adult SLE, paediatric extrapolation strategies can limit the number and complexity of studies needed to support the labelling of these medicines for use in cSLE. In this setting, specialised research networks, validated outcome measures, stakeholder input, study designs as well as statistical methods successfully used in other uncommon diseases will help improve study efficiency in an effort to enhance the speed with which new drugs for cSLE can be studied. Open-label pharmacokinetic-pharmacodynamic studies are preferred by paediatric rheumatologists over double-blind parallel designs for cSLE trials. Appropriate infrastructure, outcome measures and sufficient numbers of patients are available for the testing of new medicines for children with cSLE.
Collapse
Affiliation(s)
- Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alberto Martini
- IRCCS Istituto Giannina Gaslini, Direzione Scientifica, Genova, Italy
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Direzione Scientifica, Genova, Italy
| |
Collapse
|
25
|
Sadun RE, Schanberg LE. Transition and transfer of the patient with paediatric-onset lupus: a practical approach for paediatric and adult rheumatology practices. Lupus Sci Med 2018; 5:e000282. [PMID: 30167316 PMCID: PMC6109813 DOI: 10.1136/lupus-2018-000282] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 06/21/2018] [Indexed: 12/14/2022]
Abstract
The prevalence of paediatric-onset SLE (pSLE) is estimated at 1million people worldwide and accounts for a significant proportion of SLE morbidity, mortality and cost. Patients with pSLE are especially vulnerable during and immediately following transfer from paediatric to adult rheumatology care, when substantial delays in care and increased disease activity are common. Transition is the process through which adolescents and young adults (AYA) develop the skills needed to succeed in the adult healthcare environment, a process that typically takes several years and may span a patient's time in paediatric and adult clinics. Recommendations for improving transition and transfer for AYA with pSLE include setting expectations of the AYA patient and family concerning transition and transfer, developing AYA's self-management skills, preparing an individualised transition plan that identifies a date for transfer, transferring at a time of medical and social stability, coordinating communication between the paediatric and adult rheumatologists (inclusive of both a medical summary and key social factors), and identifying a transition coordinator as a point person for care transfer and to monitor the AYA's arrival and retention in adult rheumatology care. Of paramount importance is empowering the adult rheumatologist with skills that enhance rapport with AYA patients, engage AYA patients and families in adult care models, promote adherence and encourage ongoing development of self-management skills.
Collapse
Affiliation(s)
- Rebecca E Sadun
- Department of Pediatrics, Division of Rheumatology, Duke Health, Durham, North Carolina, USA
- Department of Medicine, Division of Rheumatology, Duke Health, Durham, North Carolina, USA
| | - Laura E Schanberg
- Department of Pediatrics, Division of Rheumatology, Duke Health, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| |
Collapse
|
26
|
Harry O, Yasin S, Brunner H. Childhood-Onset Systemic Lupus Erythematosus: A Review and Update. J Pediatr 2018; 196:22-30.e2. [PMID: 29703361 DOI: 10.1016/j.jpeds.2018.01.045] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 10/30/2017] [Accepted: 01/12/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Onengiya Harry
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shima Yasin
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Hermine Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| |
Collapse
|
27
|
IRF5 is elevated in childhood-onset SLE and regulated by histone acetyltransferase and histone deacetylase inhibitors. Oncotarget 2018; 8:47184-47194. [PMID: 28525378 PMCID: PMC5564555 DOI: 10.18632/oncotarget.17586] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 04/17/2017] [Indexed: 11/25/2022] Open
Abstract
Interferon regulatory factor 5 (IRF5) plays a critical role in the induction of type I interferon, proinflammatory cytokines and chemokines, and participates in the pathogenesis of autoimmune diseases such as systemic lupus erythematosus (SLE). However, the relationship between IRF5 and childhood-onset SLE remains elusive. In the present study, we demonstrated that levels of mRNA expression of IRF5, IFN-α, and Sp1 were significantly increased in childhood-onset SLE, as seen on quantitative real-time PCR, and the expression of Sp1 and IFN-α was positively correlated with IRF5. In addition to being used as antitumor drugs, a number of histone deacetylase inhibitors (HDACi) display potent anti-inflammatory properties; however, their effects on IRF5 expression remain unclear. In this study, we identified that HDACi trichostatin A (TSA) and histone acetyltransferase (HAT)-p300 downregulated IRF5 promoter activity, mRNA expression, and protein level, whereas the HAT-p300/CBP-associated factor had no effect. Moreover, TSA inhibited the production of TNF-α and IL-6 in differentiated THP-1cells. Furthermore, chromatin immunoprecipitation assays revealed that TSA inhibited DNA binding of Sp1, RNA polymerase II, HDAC3, and p300 to the core promoter region of IRF5. Our results suggest that HDACi may have therapeutic potential in patients with autoimmune diseases such as SLE through repression of IRF5 expression.
Collapse
|
28
|
Avar Aydin PO, Shan J, Brunner HI, Mitsnefes MM. Blood pressure control over time in childhood-onset systemic lupus erythematous. Lupus 2018; 27:657-664. [PMID: 29301473 DOI: 10.1177/0961203317751061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Hypertension (HTN) is prevalent in patients with systemic lupus erythematosus (SLE) and causes early cardiovascular aging and progression of renal and cardiac disease. The aim of this longitudinal retrospective study was to evaluate the prevalence of HTN, the follow-up blood pressure trends, and risk factors for HTN in a population-based cohort with childhood-onset SLE (cSLE). Methods Demographic and clinical data of consecutive visits from the baseline to the last visit were extracted from electronic medical records of patients with cSLE. Results A total of 110 patients with cSLE were identified with a median follow-up duration of 29.5 months; 19% had lupus nephritis (LN) at diagnosis. Further, 29% and 23% had HTN and preHTN at the baseline visit. Compared to those without HTN, patients with HTN had higher disease activity, obesity, more frequent LN, and lower eGFR. In multivariate analysis, the presence of LN, obesity, and high extra-renal disease activity were independent predictors of HTN at baseline. Conclusions While HTN is a known feature of LN, HTN is common and persistent in cSLE without LN, with about one-third of patients having uncontrolled elevated blood pressure almost three years after the onset of lupus. In addition to LN, obesity and high overall disease activity were independent predictors of HTN.
Collapse
Affiliation(s)
- P O Avar Aydin
- 1 Division of Rheumatology, 2518 Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - J Shan
- 2 34732 Peking Union Medical College Hospital , Peking, China
| | - H I Brunner
- 1 Division of Rheumatology, 2518 Cincinnati Children's Hospital , Cincinnati, OH, USA
| | - M M Mitsnefes
- 3 Division of Nephrology and Hypertension, 2518 Cincinnati Children's Hospital , Cincinnati, OH, USA
| |
Collapse
|
29
|
Tektonidou MG, Lewandowski LB, Hu J, Dasgupta A, Ward MM. Survival in adults and children with systemic lupus erythematosus: a systematic review and Bayesian meta-analysis of studies from 1950 to 2016. Ann Rheum Dis 2017; 76:2009-2016. [PMID: 28794077 DOI: 10.1136/annrheumdis-2017-211663] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/05/2017] [Accepted: 07/18/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine trends in survival among adult and paediatric patients with systemic lupus erythematosus (SLE) from 1950 to the present. METHODS We performed a systematic literature review to identify all published cohort studies on survival in patients with SLE. We used Bayesian methods to derive pooled survival estimates separately for adult and paediatric patients, as well as for studies from high-income countries and low/middle-income countries. We pooled contemporaneous studies to obtain trends in survival over time. We also examined trends in major causes of death. RESULTS We identified 125 studies of adult patients and 51 studies of paediatric patients. Among adults, survival improved gradually from the 1950s to the mid-1990s in both high-income and low/middle-income countries, after which survival plateaued. In 2008-2016, the 5-year, 10-year and 15-year pooled survival estimates in adults from high-income countries were 0.95, 0.89 and 0.82, and in low/middle-income countries were 0.92, 0.85 and 0.79, respectively. Among children, in 2008-2016, the 5-year and 10-year pooled survival estimates from high-income countries were 0.99 and 0.97, while in low/middle-income countries were 0.85 and 0.79, respectively. The proportion of deaths due to SLE decreased over time in studies of adults and among children from high-income countries. CONCLUSIONS After a period of major improvement, survival in SLE has plateaued since the mid-1990s. In high-income countries, 5-year survival exceeds 0.95 in both adults and children. In low/middle-income countries, 5-year and 10-year survival was lower among children than adults.
Collapse
Affiliation(s)
- Maria G Tektonidou
- Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Laura B Lewandowski
- National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Intramural Research Program, Bethesda, Maryland, USA
| | - Jinxiang Hu
- National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Intramural Research Program, Bethesda, Maryland, USA
| | - Abhijit Dasgupta
- National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Intramural Research Program, Bethesda, Maryland, USA
| | - Michael M Ward
- National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Intramural Research Program, Bethesda, Maryland, USA
| |
Collapse
|
30
|
Thong B, Olsen NJ. Systemic lupus erythematosus diagnosis and management. Rheumatology (Oxford) 2017; 56:i3-i13. [PMID: 28013206 DOI: 10.1093/rheumatology/kew401] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Indexed: 01/07/2023] Open
Abstract
SLE presents many challenges for clinicians. The onset of disease may be insidious, with many different symptoms and signs, making early and accurate diagnosis challenging. Tests for SLE in the early stages lack specificity; those that are useful later often appear only after organ damage is manifest. Disease patterns are highly variable; flares are not predictable and not always associated with biomarkers. Children with SLE may have severe disease and present special management issues. Older SLE patients have complicating co-morbid conditions. Therapeutic interventions have improved over recent decades, but available drugs do not adequately control disease in many patients, and successful outcomes are limited by off-target effects; some of these become manifest with longer duration of treatment, now in part revealed by improved rates of survival. Despite all of these challenges, advances in understanding the biological basis of SLE have translated into more effective approaches to patient care. This review considers the current state of SLE diagnosis and management, with a focus on new approaches and anticipated advances.
Collapse
Affiliation(s)
- Bernard Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Nancy J Olsen
- Division of Rheumatology, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
31
|
Abstract
Bone health in children with rheumatic conditions may be compromised due to several factors related to the inflammatory disease state, delayed puberty, altered life style, including decreased physical activities, sun avoidance, suboptimal calcium and vitamin D intake, and medical treatments, mainly glucocorticoids and possibly some disease-modifying anti-rheumatic drugs. Low bone density or even fragility fractures could be asymptomatic; therefore, children with diseases of high inflammatory load, such as systemic onset juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, and those requiring chronic glucocorticoids may benefit from routine screening of bone health. Most commonly used assessment tools are laboratory testing including serum 25-OH-vitamin D measurement and bone mineral density measurement by a variety of methods, dual-energy X-ray absorptiometry as the most widely used. Early disease control, use of steroid-sparing medications such as disease-modifying anti-rheumatic drugs and biologics, supplemental vitamin D and calcium, and promotion of weight-bearing physical activities can help optimize bone health. Additional treatment options for osteoporosis such as bisphosphonates are still controversial in children with chronic rheumatic diseases, especially those with decreased bone density without fragility fractures. This article reviews common risk factors leading to compromised bone health in children with chronic rheumatic diseases and discusses the general approach to prevention and treatment of bone fragility.
Collapse
|
32
|
Advances in the care of children with lupus nephritis. Pediatr Res 2017; 81:406-414. [PMID: 27855151 DOI: 10.1038/pr.2016.247] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/07/2016] [Indexed: 12/27/2022]
Abstract
The care of children with lupus nephritis (LN) has changed dramatically over the past 50 y. The majority of patients with childhood-onset systemic lupus erythematosus (cSLE) develop LN. In the 1960's, prognosis in children was worse than in adults; therapies were limited and toxic. Nearly half of cases resulted in death within 2 y. Since this time, several diagnostic recommendations and disease-specific indices have been developed to assist physicians caring for patients with LN. Pediatric researchers are validating and adapting these indices and guidelines for the treatment of LN in cSLE. Classification systems, activity, and chronicity indices for kidney biopsy have been validated in pediatric cohorts in several countries. Implementation of contemporary immunosuppressive agents has reduced treatment toxicity and improved outcomes. Biomarkers sensitive to LN in children have been identified in the kidney, urine, and blood. Multi-institutional collaborative networks have formed to address the challenges of pediatric LN research. Considerable variation in evaluation and treatment has been addressed for proliferative forms of LN by development of consensus treatment practices. Patient survival at 5 y is now 95-97% and renal survival exceeds 90%. Moreover, international consensus exists for quality indicators for cSLE that consider the unique aspects of chronic disease in childhood.
Collapse
|
33
|
Zahidy AH, Azizan NA, Sorooshian S. An Analytical Algorithm for Delphi Method for Consensus Building and Organizational Productivity. ADVANCES IN BUSINESS INFORMATION SYSTEMS AND ANALYTICS 2017:62-79. [DOI: 10.4018/978-1-5225-0654-6.ch004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
The Delphi technique is being increasingly used in many complex areas where a consensus is to be reached. In such an environment, the Delphi technique allows researchers to acquire high quality, unbiased information from a panel of certified experts. Despite its vast uses, the Delphi method has seen a lack of consistent procedural guidance for its application. A review of literature revealed a significant variation in methodological approach of the method. The purpose of this paper is to develop a practical algorithm for the Delphi study application based on the literature review and the authors' practiced experiences. A few modifications are suggested to make the Delphi study more practical in research and decision making. Using the guidelines provided by this paper, it is expected that the reader may better understand the appropriate application and procedure of the modified Delphi process.
Collapse
|
34
|
Harris JG, Maletta KI, Kuhn EM, Olson JC. Evaluation of quality indicators and disease damage in childhood-onset systemic lupus erythematosus patients. Clin Rheumatol 2016; 36:351-359. [PMID: 28013435 DOI: 10.1007/s10067-016-3518-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/11/2016] [Accepted: 12/14/2016] [Indexed: 01/30/2023]
Abstract
The aim of this study was to describe compliance with select quality indicators and assess organ-specific dysfunction in a childhood-onset systemic lupus erythematosus population by using a validated damage index and to evaluate associations between compliance with quality indicators and disease damage. A retrospective chart review was performed on patients diagnosed with systemic lupus erythematosus prior to age 18 followed at a single center in the USA from 1999 to 2012 (n = 75). Data regarding quality indicators and outcome variables, including the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, were collected. The median disease duration was 3.8 years. The proportion of patients or patient-years in which care complied with the proposed quality measures was 94.4% for hydroxychloroquine use, 84.3% for vitamin D recommendation,75.8% for influenza vaccination (patient-years), 67.2% for meningococcal vaccination, 49.0% for ophthalmologic examination (patient-years), 31.7% for pneumococcal vaccination, and 28.6% for bone mineral density evaluation. Disease damage was present in 41.3% of patients at last follow-up, with an average damage index score of 0.81. Disease damage at last follow-up was associated with minority race/ethnicity (p = 0.008), bone mineral density evaluation (p = 0.035), and vitamin D recommendation (p = 0.018). Adherence to quality indicators in a childhood-onset systemic lupus erythematosus population is varied, and disease damage is prevalent. This study highlights the importance of quality improvement initiatives aimed at optimizing care delivery to reduce disease damage in pediatric lupus patients.
Collapse
Affiliation(s)
- Julia G Harris
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO, USA. .,University of Missouri - Kansas City School of Medicine, Kansas City, MO, USA.
| | - Kristyn I Maletta
- Department of Business Intelligence and Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Evelyn M Kuhn
- Department of Business Intelligence and Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Judyann C Olson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
35
|
Hayward K, Haaland WL, Hrachovec J, Leu M, Vora S, Clifton H, Rascoff N, Crowell CS. Reliable Pregnancy Testing Before Intravenous Cyclophosphamide: A Quality Improvement Study. Pediatrics 2016; 138:peds.2016-0378. [PMID: 27940668 DOI: 10.1542/peds.2016-0378] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Cyclophosphamide is a teratogenic medication used in the treatment of adolescents with autoimmune disorders. This adolescent population is sexually active, does not receive adequate contraceptive care, and is at risk for unintended pregnancy. We undertook a quality improvement initiative to improve rates of pregnancy screening before intravenous cyclophosphamide administration in our adolescent girl patients. METHODS Data were collected from the electronic medical record. The primary outcome was completion of a urine pregnancy test before intravenous cyclophosphamide infusion in girls aged 12 to 21 years between July 2011 and June 2015. Data were reviewed quarterly and an iterative quality improvement approach was used. Interventions included staff education, electronic order set updates, and a Maintenance of Certification project. Interrupted time series analysis and multivariable mixed effects logistic regression were used to evaluate trends over time and to adjust for potential confounders. RESULTS Thirty girls received 153 cyclophosphamide infusions during the study. Pregnancy testing before medication administration increased from 25% to 100% by study completion. Infusions in the last time period were significantly more likely to be accompanied by a pregnancy test versus those in the first time period (odds ratio: 17.7; 95% confidence interval [CI]: 3.1-101.6) after adjustment for patient age, managing service, infusion setting, and insurance type. CONCLUSIONS Our institution achieved a significant increase in standard pregnancy screening in adolescent girls receiving intravenous cyclophosphamide. The interventions most valuable in increasing screening rates were updating electronic order sets, educating staff, and physician engagement in the Maintenance of Certification program.
Collapse
Affiliation(s)
| | - Wren L Haaland
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; and
| | - Jennifer Hrachovec
- Clinical Effectiveness, Seattle Children's Hospital, Seattle, Washington
| | - Michael Leu
- Departments of Pediatrics, and.,Clinical Effectiveness, Seattle Children's Hospital, Seattle, Washington.,Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington
| | - Surabhi Vora
- Departments of Pediatrics, and.,Clinical Effectiveness, Seattle Children's Hospital, Seattle, Washington
| | - Holly Clifton
- Clinical Effectiveness, Seattle Children's Hospital, Seattle, Washington
| | | | - Claudia S Crowell
- Departments of Pediatrics, and.,Clinical Effectiveness, Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
36
|
Basiaga ML, Burrows EK, Denburg MR, Meyers KE, Grossman AB, Mamula P, Grundmeier RW, Burnham JM. Variation in Preventive Care in Children Receiving Chronic Glucocorticoid Therapy. J Pediatr 2016; 179:226-232. [PMID: 27622698 PMCID: PMC5123921 DOI: 10.1016/j.jpeds.2016.08.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/26/2016] [Accepted: 08/10/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess preventive care measure prescribing in children exposed to glucocorticoids and identify prescribing variation according to subspecialty and patient characteristics. STUDY DESIGN Retrospective cohort study of children initiating chronic glucocorticoids in the gastroenterology, nephrology, and rheumatology divisions at a pediatric tertiary care center. Outcomes included 25-hydroxyvitamin D (25OHD) and lipid testing, pneumococcal polysaccharide (PPV) and influenza vaccination, and stress dose hydrocortisone prescriptions. RESULTS A total of 701 children were followed for a median of 589 days. 25OHD testing was performed in 73%, lipid screening in 29%, and PPV and influenza vaccination in 16% and 78%, respectively. Hydrocortisone was prescribed in 2%. Across specialties, 25OHD, lipid screening, and PPV prescribing varied significantly (all P < .001). Using logistic regression adjusting for specialty, 25OHD testing was associated with older age, female sex, non-Hispanic ethnicity, and lower baseline height and body mass index z-scores (all P < .03). Lipid screening was associated with older age, higher baseline body mass index z-score, and lower baseline height z-score (all P < .01). Vaccinations were associated with lower age (P < .02), and PPV completion was associated with non-White race (P = .04). CONCLUSIONS Among children chronically exposed to glucocorticoids, 25OHD testing and influenza vaccination were common, but lipid screening, pneumococcal vaccination, and stress dose hydrocortisone prescribing were infrequent. Except for influenza vaccination, preventive care measure use varied significantly across specialties. Quality improvement efforts are needed to optimize preventive care in this high-risk population.
Collapse
Affiliation(s)
- Matthew L Basiaga
- Division of Rheumatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Evanette K Burrows
- Division of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Michelle R Denburg
- Division of Nephrology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Kevin E Meyers
- Division of Nephrology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Andrew B Grossman
- Division of Gastroenterology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Petar Mamula
- Division of Gastroenterology, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Robert W Grundmeier
- Division of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Division of General Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania
| | - Jon M Burnham
- Division of Rheumatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
37
|
Thakral A, Klein-Gitelman MS. An Update on Treatment and Management of Pediatric Systemic Lupus Erythematosus. Rheumatol Ther 2016; 3:209-219. [PMID: 27747587 PMCID: PMC5127968 DOI: 10.1007/s40744-016-0044-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Indexed: 12/17/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disorder in which 20 % of patients are diagnosed in childhood. Childhood-onset SLE is associated with higher morbidity and mortality than adult-onset SLE. The aims of disease management with early immunosuppression are to decrease disease activity and improve quality of life. A multidisciplinary approach is necessary due to the complexity of lupus in pediatric patients. It is important to provide patients with high quality of care and to instill ownership of their disease process from a young age to prepare them to manage this life-long illness. This article reviews current management of SLE in children.
Collapse
Affiliation(s)
- Amit Thakral
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA.
| | - Marisa S Klein-Gitelman
- Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| |
Collapse
|
38
|
Abstract
Pediatricians and other pediatric health care providers in primary care settings are often faced with the challenge of evaluating patients with suspected autoimmune disorders. The first and most important step in evaluating children with suspected autoimmune disorders is taking a detailed history and performing a thorough physical examination. This step helps narrow the diagnosis, and thus helps determine appropriate laboratory evaluations. The results of laboratory tests need to be interpreted within the clinical context. It is also important to recognize that the laboratory tests have different diagnostic values in children as compared to adults. [Pediatr Ann. 2016;45(7):e265-e271.].
Collapse
|
39
|
Mina R, Harris JG, Klein-Gitelman MS, Appenzeller S, Centeville M, Eskra D, Huggins JL, Johnson AL, Khubchandani R, Khandekar P, Lee J, Liu HM, Pendl JD, Silva CA, Silva MF, Zaal AI, DeWitt EM, Ardoin SP, Brunner HI. Initial Benchmarking of the Quality of Medical Care in Childhood-Onset Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2016. [PMID: 26219749 DOI: 10.1002/acr.22666] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To assess the quality of medical care in childhood-onset systemic lupus erythematosus (SLE) at tertiary pediatric rheumatology centers as measured by observance of SLE quality indicators (SLE-QIs). METHODS International consensus has been achieved for childhood-onset SLE-QIs capturing medical care provision in 9 domains: diagnostic testing, education of cardiovascular (CV) risk and lifestyles, lupus nephritis (LN), medication management, bone health, ophthalmologic surveillance, transition, pregnancy, and vaccination. Using medical record information, the level of performance of these childhood-onset SLE-QIs was assessed in childhood-onset SLE populations treated at 4 tertiary pediatric rheumatology centers in the US, 2 in Brazil, and 1 center in India. RESULTS A total of 483 childhood-onset SLE patients were assessed. Care for the 310 US patients differed markedly for childhood-onset SLE-QIs addressing LN, bone health, vaccinations, education on CV risk, and transition planning. Performance of safety blood testing for medications was high at all centers. Despite often similar performance on the childhood-onset SLE-QI, access to kidney biopsies was lower in Brazil than in the US. Irrespective of the country of practice, larger centers tended to meet the childhood-onset SLE-QIs more often than smaller centers. CONCLUSION The childhood-onset SLE-QIs, evidence-based minimum standards of medical care, are not consistently met in the US or some other countries outside the US. This has the potential to contribute to suboptimal childhood-onset SLE outcomes.
Collapse
Affiliation(s)
- Rina Mina
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Julia G Harris
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | | | | | | | - Diane Eskra
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Anne L Johnson
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Jiha Lee
- University of Cincinnati, Cincinnati, Ohio
| | - Hai Mei Liu
- Children's Hospital of Fudan University, Shanghai, China
| | - Joshua D Pendl
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Ahmad I Zaal
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Stacy P Ardoin
- Nationwide Children's Hospital and Ohio State University, Columbus, Ohio
| | | |
Collapse
|
40
|
Sato JO, Corrente JE, Saad-Magalhães C. Correlation between the Modified Systemic Lupus Erythematosus Disease Activity Index 2000 and the European Consensus Lupus Activity Measurement in juvenile systemic lupus erythematosus. Lupus 2016; 25:1479-1484. [PMID: 27230556 DOI: 10.1177/0961203316651737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective The objective of this study was to assess Modified Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) and European Consensus Lupus Activity Measurement (ECLAM) disease activity correlation in addition to their respective correlation to Pediatric Systemic Lupus International Collaborative Clinics/American College of Rheumatology (SLICC/ACR) Damage Index (Ped-SDI), in juvenile systemic lupus erythematosus (JSLE). Methods The activity indices were scored retrospectively and summarized by adjusted means during follow-up. The Ped-SDI was scored during the last visit for those with more than six months follow-up. Pearson correlation between the Modified SLEDAI-2K and ECLAM, as well as Spearman correlations between the Modified SLEDAI-2K, ECLAM, and Ped-SDI were calculated. The receiver operating characteristic (ROC) curve was calculated for both activity indices discriminating damage measured by Ped-SDI. Results Thirty-seven patients with mean age at diagnosis 11 ± 2.9 years and mean follow-up time 3.2 ± 2.4 years were studied. The Modified SLEDAI-2K and ECLAM adjusted means were highly correlated ( r = 0.78, p < 0.001). Similarly, Spearman correlation between the activity indices was also high ( rs > 0.7, p < 0.001), but Modified SLEDAI-2K and ECLAM correlation with Ped-SDI was only moderate. ROC analysis discriminant performance for both activity indices resulted in area under curve (AUC) of 0.74 and 0.73 for Modified SLEDAI-2K and ECLAM, respectively. Conclusion The high correlation found between the Modified SLEDAI-2K and ECLAM adjusted means indicated that both tools can be equally useful for longitudinal estimates of JSLE activity.
Collapse
Affiliation(s)
- J O Sato
- 1 Departamento de Pediatria, Faculdade de Medicina de Botucatu, UNESP-Universidade Estadual Paulista, São Paulo, Brazil
| | - J E Corrente
- 2 Departamento de Bioestatística, Instituto de Biociências, Campus de Botucatu, UNESP-Universidade Estadual Paulista, São Paulo, Brazil
| | - C Saad-Magalhães
- 1 Departamento de Pediatria, Faculdade de Medicina de Botucatu, UNESP-Universidade Estadual Paulista, São Paulo, Brazil
| |
Collapse
|
41
|
Abstract
PURPOSE OF REVIEW This article highlights efforts in pediatric rheumatology related to optimizing the care provided to patients with pediatric rheumatic diseases and describes various approaches to improve health outcomes. RECENT FINDINGS Recent studies report low rates of remission, frequent occurrence of comorbidities, disease damage, and decreased health-related quality of life in pediatric rheumatic diseases. The Pediatric Rheumatology Care and Outcomes Improvement Network is a quality improvement learning network that has demonstrated improvement in the process of care measures through use of a centralized patient registry, and interventions, including previsit planning, population management, shared decision making, and patient/parent engagement. A pediatric rheumatology patient-powered research network was established to enable patient and caregiver participation in setting research priorities and to facilitate data sharing to answer research questions. Quality measure development and benchmarking are proceeding in multiple pediatric rheumatic diseases. SUMMARY The review summarizes the current efforts to improve care delivery and outcomes in pediatric rheumatic diseases through a learning health system approach that harnesses knowledge from the clinical encounter to serve quality improvement, research, and discovery. Incorporating standard approaches to medication treatment plans may reduce variation in care, including using the patient voice to design research studies to bring focus on more patient relevant outcomes. VIDEO ABSTRACT http://links.lww.com/COR/A28.
Collapse
Affiliation(s)
| | | | - Esi M. Morgan
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
42
|
Silva CA, Aikawa NE, Pereira RMR, Campos LMA. Management considerations for childhood-onset systemic lupus erythematosus patients and implications on therapy. Expert Rev Clin Immunol 2015; 12:301-13. [DOI: 10.1586/1744666x.2016.1123621] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Clovis Artur Silva
- Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nadia Emi Aikawa
- Pediatric Rheumatology Unit, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | | |
Collapse
|
43
|
Harris JG, Maletta KI, Ren B, Olson JC. Improving Pneumococcal Vaccination in Pediatric Rheumatology Patients. Pediatrics 2015; 136:e681-6. [PMID: 26304825 DOI: 10.1542/peds.2014-2512] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Many pediatric rheumatology patients are at increased risk of pneumococcal disease secondary to a deficient immune system and/or immunosuppressive medications. The goal of this study was to improve pneumococcal vaccination rates in this high-risk population. METHODS Eligible patients included children at least 2 years old and adults with systemic lupus erythematosus and/or currently on immunosuppressive medication. Interventions included a presentation to rheumatology providers,creation of immunization algorithm, previsit planning, placing reminders on clinic forms, and sending reminder e-mails to providers. Chart reviews were performed, and control charts were established to portray change in immunization rates. RESULTS The preintervention immunization rates for 90 patient visits compared with the immunization rates for the 53-week postintervention period with 1033 patient visits and 299 separate patients were all statistically significant.The 13-valent pneumococcal conjugate vaccine rate increased from 6.7% to48.4% (x2 = 58.3, P , .001), 23-valent pneumococcal polysaccharide vaccinerate increased from 8.9% to 28.4% (x2 = 16.0, P , .001), and combined rate increased from 0% to 23.2% (x2 = 25.2, P , .001). The improvement was sustained with shifts in the data for each vaccine and combined immunizations for final average rates of 60.9% for 13-valent pneumococcal conjugate vaccine, 39.2% for 23-valent pneumococcal polysaccharide vaccine,and 33.7% for combined. CONCLUSIONS Pneumococcal vaccination is an important part of the care for systemic lupus erythematosus patients and patients on immunosuppressive medications. Simple interventions through this quality improvement project led to a marked increase in pneumococcal vaccination rates in this vulnerable population.
Collapse
Affiliation(s)
- Julia G. Harris
- Division of Rheumatology, Department of Pediatrics, Children’s Mercy-Kansas City, Kansas City, Missouri
| | - Kristyn I. Maletta
- National Outcomes Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and
| | - Bixiang Ren
- National Outcomes Center, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin; and
| | - Judyann C. Olson
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
44
|
|
45
|
Aggarwal A, Srivastava P. Childhood onset systemic lupus erythematosus: how is it different from adult SLE? Int J Rheum Dis 2014; 18:182-91. [PMID: 24965742 DOI: 10.1111/1756-185x.12419] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
About 20% of systemic lupus erythematosus (SLE) starts in childhood and children have less gender bias in favor of females as compared to adults. Systemic manifestations, nephritis, neuro-psychiatric disease and cytopenias are more common in children at presentation than adults. Since most children develop lupus in their early adolescence, dealing with the diagnosis of an unpredictable lifelong disease during this phase of life is challenging. Physicians must recognise specific medical and social needs of this age group, for optimal long-term outcome. Steroids and immunosuppressive drugs are the cornerstone for treatment in children as with adults with lupus. The outcome has improved considerably with these drugs and 10-year survival is nearly 90%. Due to longer life spans more damage accrues in children as compared to adults. Most of the drugs are associated with significant toxicity and the goal of having a drug which reduces disease activity and damage without hampering normal growth, development and fertility is still an elusive one. The current review focuses on clinical and immunological aspects of childhood SLE and how it differs from adulthood SLE.
Collapse
Affiliation(s)
- Amita Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | |
Collapse
|
46
|
Mina R, Brunner HI. Update on differences between childhood-onset and adult-onset systemic lupus erythematosus. Arthritis Res Ther 2013; 15:218. [PMID: 23998441 PMCID: PMC3978647 DOI: 10.1186/ar4256] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disease and occurs worldwide in both children and adults. The estimated annual incidence among children is 2.22/100,000 and among adults is 23.2/100,000 in the United States. There is increasing understanding about differences in disease manifestations, medication use, and disease severity between those with childhood-onset SLE as compared with adult-onset SLE. Children have a more fulminant disease onset and course than adults with SLE, resulting in two to three times higher mortality. In future years, we anticipate more insight into the genetics between childhood-onset SLE and adult-onset SLE to help delineate the best therapies for both subsets of patients.
Collapse
|
47
|
Abstract
Lupus nephritis is a common complication of systemic lupus erythematosus in children and adolescents. This article reviews the clinical relevance of lupus nephritis and its current treatment. The reader is introduced to novel biomarkers that are expected to improve the management of lupus nephritis in the future, and support the testing of novel medication regimens.
Collapse
Affiliation(s)
- Michael Bennett
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, MC 7022, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | | |
Collapse
|
48
|
Lehman TJA. Where are the innovations in paediatric rheumatology? Nat Rev Rheumatol 2013; 9:326-7. [DOI: 10.1038/nrrheum.2013.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|