1
|
Whittier M, Bautista Sanchez R, Arora S, Manadan AM. Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome as Risk Factors for Acute Coronary Syndrome in Young Patients: Analysis of the National Inpatient Sample. J Clin Rheumatol 2022; 28:143-146. [PMID: 35293887 DOI: 10.1097/rhu.0000000000001824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to compare the odds of acute coronary syndrome (ACS) in patients aged 18 to 40 years to patients older than 40 years with and without secondary diagnoses of systemic lupus erythematosus (SLE) or antiphospholipid antibody syndrome (APLS) while controlling for traditional cardiovascular (CV) risk factors. METHODS Data were extracted from the National Inpatient Sample database from 2016 to 2018. The National Inpatient Sample was searched for hospitalizations of adult patients with ACS as the principal diagnosis, with and without SLE or APLS as secondary diagnoses. Age was divided categorically into 2 groups: adults aged 18 to 40 years and those older than 40 years. The primary outcome was the development of ACS. Multivariate logistic regression analyses were used to adjust for confounders. RESULTS There were 90,879,561 hospital discharges in the 2016 to 2018 database. Of those, 55,050 between the ages of 18 to 40 years and 1,966,234 aged older than 40 years were hospitalized with a principal diagnosis of ACS. Traditional CV risk factors were associated with ACS hospitalizations in both age groups. In multivariate analysis of the 18 to 40 years age group, both SLE (odds ratio, 2.18; 95% confidence interval, 1.814-2.625) and APLS (odds ratio, 2.18; 95% confidence interval, 1.546-3.087) were strongly associated with ACS hospitalizations. After the age of 40 years, there were no increased odds of ACS hospitalizations for SLE or APLS. CONCLUSIONS In the younger population, SLE and APLS were strongly associated with ACS hospitalizations in addition to the traditional CV risk factors. In the older age group, traditional CV risk factors dominated and diluted the effect of SLE and APLS.
Collapse
|
2
|
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
|
3
|
Saito M, Yajima N, Yanai R, Tsubokura Y, Ichinose K, Yoshimi R, Ohno S, Sada KE. Prevalence and treatment conditions for hypertension and dyslipidaemia complicated with systemic lupus erythematosus: A multi-centre cross-sectional study. Lupus 2021; 30:1146-1153. [PMID: 33794706 DOI: 10.1177/09612033211006790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study aimed to assess the prevalence and actual treatment conditions for hypertension and dyslipidaemia complicated with systemic lupus erythematosus (SLE). METHODS This was a cross-sectional study. We established the lupus registry of nationwide institutions (LUNA), a multi-centre cohort of SLE patients in Japan. From February 2016 to July 2018, 597 SLE patients were registered in the LUNA. We evaluated the incidence of hypertension and dyslipidaemia and analysed the risk factors for hypertension and dyslipidaemia by logistic regression analysis. RESULTS Overall, 597 patients were enrolled in the study. The median age was 44 years, and 88.0% of the patients were female. Among all the patients, 92.9% used prednisolone. The prevalence of hypertension and dyslipidaemia was 43.9% and 54.7%, respectively. Among the patients receiving medication for hypertension, 24.7% exhibited insufficient control (systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg), and among those receiving medication for hyperlipidaemia, 48.1% showed insufficient control (low-density lipoprotein cholesterol >140 mg/dL or triglyceride >150 mg/dL). The risk factors for hypertension were age, body mass index (BMI), disease duration, past maximum dose of prednisolone, and renal involvement, whereas those for dyslipidaemia were age and BMI. CONCLUSION About half of the patients had hypertension or dyslipidaemia, and a considerable number of cases were poorly controlled despite medication. Our data suggest that physicians should treat SLE activity as well as its complications, especially the common risk factors for atherosclerosis.
Collapse
Affiliation(s)
- Mayu Saito
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan.,Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yumi Tsubokura
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Advanced Preventive Medical Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Shigeru Ohno
- Center for Rheumatic Diseases, Yokohama City University Medical Center, Yokohama, Japan
| | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.,Department of Clinical Epidemiology, Kochi Medical School, Kochi University, Kochi, Japan
| |
Collapse
|
4
|
Abel D, Ardoin SP, Gorelik M. The potential role of Colchicine in preventing coronary vascular disease in childhood-onset lupus: a new view on an old drug. Pediatr Rheumatol Online J 2021; 19:15. [PMID: 33593369 PMCID: PMC7885423 DOI: 10.1186/s12969-021-00504-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/08/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Patients with systemic lupus erythematous have a significantly increased risk of cardiovascular disease, which is not fully explained by traditional cardiovascular disease risk factors. Despite increasing life expectancy in patients with systemic lupus erythematous, mortality due to cardiovascular disease, the major cause of death in these patients, has not changed. Children with lupus suffer from more aggressive disease compared to their adult counterparts, and there is a growing concern for their increased risk of cardiovascular disease as they age. BODY: There is an unmet need for therapies to address the increased risk of cardiovascular disease in childhood-onset lupus. Colchicine has many anti-inflammatory and cardiovascular protective properties, including inhibition of IL-1β and IL-18 activity, key proinflammatory cytokines that are predictive of future adverse cardiovascular events. In the Colchicine Cardiovascular Outcomes Trial (COLCOT), colchicine was recently found to have significant benefit with minimal risk in adults with previous myocardial infarction for prevention of secondary vascular disease. While adult studies are promising, no studies have been conducted in pediatric patients to investigate colchicine's potential for cardiovascular protection in children and adolescents with lupus. CONCLUSIONS Studies investigating colchicine's potential role for cardiovascular protection are needed in pediatric patients with systemic lupus erythematous.
Collapse
Affiliation(s)
- Dori Abel
- Department of Pediatrics, NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, 630 W. 168th Street, New York, NY, 10032-3702, USA.
| | - Stacy P. Ardoin
- grid.261331.40000 0001 2285 7943Department of Medicine, Division of Rheumatology and Immunology, The Ohio State University, 370 W. 9th Ave, Columbus, OH 43210 USA ,grid.240344.50000 0004 0392 3476Department of Rheumatology, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205 USA
| | - Mark Gorelik
- grid.21729.3f0000000419368729Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, Columbia University Irving Medical Center, 630 W. 168th St, New York, NY 10032-3702 USA
| |
Collapse
|
5
|
Bağlan Yentür S, Karatay S, Oskay D, Tufan A, Küçük H, Haznedaroğlu Ş. Kinesiophobia and related factors in systemic lupus erythematosus patients. Turk J Med Sci 2019; 49:1324-1331. [PMID: 31648437 PMCID: PMC7018320 DOI: 10.3906/sag-1804-152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 05/29/2019] [Indexed: 01/01/2023] Open
Abstract
Background/aim This study was designed to investigate the relationship between kinesiophobia and the level of physical activity, depression, disease activity, fatigue, pain, and quality of life in female patients with systemic lupus erythematosus (SLE). Materials and methods Seventy volunteer female patients were included in the study. Kinesiophobia, physical activity level, disease activity, fatigue, depression, pain, and quality of life were assessed using the Tampa Scale for Kinesiophobia (TSK), International Physical Activity Questionnaire- Short Form (IPAQ), Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), Fatigue Severity Scale (FSS), Beck Depression Inventory (BDI), McGill Pain Questionnaire- Short Form (MPQ-SF) and Nottingham Health Profile (NHP), respectively. Results Two-thirds of the patients in the study had a high degree of kinesiophobia. Although there was a significant correlation between kinesiophobia and depression and some subscales of quality of life (sleep, social isolation, emotional reactions) (P < 0.05), no significant correlation with other parameters was found. Conclusion As a result of this study, the majority of SLE patients included in the study were identified as having high levels of kinesiophobia. Patients’ fear and avoidance reaction from movement can be influenced by psychosocial factors. Treatments focusing on kinesiophobia of SLE patients could be beneficial in increasing the success of rehabilitation.
Collapse
Affiliation(s)
- Songül Bağlan Yentür
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Gazi University, Ankara, Turkey
| | - Saliha Karatay
- Department of Physical Medicine and Rehabilitation, A Life Park Hospital, Ankara, Turkey
| | - Deran Oskay
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Gazi University, Ankara, Turkey
| | - Abdurrahman Tufan
- Division of Rheumatology, Faculty of Medical Sciences, Gazi University
| | - Hamit Küçük
- Erzurum Regional Education Hospital, Erzurum, Turkey
| | - Şeminur Haznedaroğlu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Gazi University, Ankara, Turkey
| |
Collapse
|
6
|
Chen SK, Barbhaiya M, Fischer MA, Guan H, Lin TC, Feldman CH, Everett BM, Costenbader KH. Lipid Testing and Statin Prescriptions Among Medicaid Recipients With Systemic Lupus Erythematosus or Diabetes Mellitus and the General Medicaid Population. Arthritis Care Res (Hoboken) 2019; 71:104-115. [PMID: 29648687 DOI: 10.1002/acr.23574] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Accepted: 04/03/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Cardiovascular disease (CVD) risks in systemic lupus erythematosus (SLE) are similar to those in diabetes mellitus (DM). We investigated whether the numbers of lipid tests and statin prescriptions in patients with SLE are comparable with those in patients with DM and those in individuals without either disease. METHODS Using Analytic eXtract files from 29 states for 2007-2010, we identified a cohort of US Medicaid beneficiaries, ages 18-65 years, with prevalent SLE. Each SLE patient was matched for age and sex with 2 patients with DM and 4 individuals in the general Medicaid population who did not have either SLE or DM. We compared the proportions of patients in each cohort who received ≥1 lipid test and ≥1 statin prescription during 1-year follow-up. We used multivariable logistic regression to calculate the odds of lipid testing and receiving prescriptions for statins and conditional logistic regression to compare the matched cohorts. RESULTS We identified 3 Medicaid cohorts: 25,950 patients with SLE, 51,900 patients with DM, and 103,800 Medicaid recipients without either condition. In these cohorts, lipid testing was performed in 24% of patients in the SLE group, 43% of patients in the DM group, and 16% of individuals in the group with neither condition, and statin prescriptions were dispensed in 11%, 33%, and 7% of these groups, respectively. SLE patients were 66% less likely (odds ratio [OR] 0.34, 95% confidence interval [95% CI] 0.34-0.35) to have lipid tests and 82% less likely (OR 0.18, 95% CI 0.18-0.18) to fill a statin prescription compared with DM patients. SLE patients were also less likely (OR 0.89, 95% CI 0.84-0.94) to fill a statin prescription compared with individuals in the general Medicaid population. CONCLUSION Despite having an elevated risk of CVD, SLE patients received less lipid testing and received fewer statin prescriptions compared with age- and sex-matched DM patients and individuals in the general Medicaid population; this gap should be a target for improvement.
Collapse
Affiliation(s)
- Sarah K Chen
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Hongshu Guan
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | | | | |
Collapse
|
7
|
Castro LL, Lanna CCD, Ribeiro ALP, Telles RW. Recognition and control of hypertension, diabetes, and dyslipidemia in patients with systemic lupus erythematosus. Clin Rheumatol 2018; 37:2693-2698. [DOI: 10.1007/s10067-018-4169-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 04/25/2018] [Accepted: 06/04/2018] [Indexed: 11/29/2022]
|
8
|
Kim SK, Choe JY, Lee SS. Self-Reported Physical Activity Is Associated with Lupus Nephritis in Systemic Lupus Erythematosus: Data from KORean Lupus Network (KORNET) Registry. Yonsei Med J 2018; 59:857-864. [PMID: 30091319 PMCID: PMC6082985 DOI: 10.3349/ymj.2018.59.7.857] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to identify the associations among physical activity, disease activity, and organ damage in patients with systemic lupus erythematosus (SLE). MATERIALS AND METHODS A total of 415 patients with SLE were consecutively enrolled from the KORean lupus Network (KORNET) registry. This registry assessed clinical features, disease activity [Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K)], and organ damage [Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index (SDI)] upon enrollment in the study. Self-reported physical activity was measured by the International Physical Activity Questionnaire. Statistical analyses were conducted using the Mann-Whitney U test and multivariate logistic regression analysis. RESULTS A significant difference in vigorous activity was noted between patients with lupus nephritis (LN) (n=93) and those without LN (n=322) (p=0.012), but not in moderate and walking activities. In contrast, no differences in physical activity, walking, moderate, and vigorous intensity, according to SLEDAI-2K and SDI were found. In addition to younger age (p=0.032), high physical component summary of SF-36 (p=0.004) and SLEDAI-2K (p=0.038), and less vigorous physical activity were associated with LN (p=0.024). However, cardiovascular disease was not associated with physical activity in SLE patients. CONCLUSION This study showed that patients with LN had less vigorous physical activity than patients without LN. The results suggest that lupus nephritis might be associated with physical activity.
Collapse
Affiliation(s)
- Seong Kyu Kim
- Division of Rheumatology, Department of Internal Medicine, Arthritis & Autoimmunity Research Center, Daegu Catholic University School of Medicine, Daegu, Korea.
| | - Jung Yoon Choe
- Division of Rheumatology, Department of Internal Medicine, Arthritis & Autoimmunity Research Center, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Shin Seok Lee
- Department of Rheumatology, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
9
|
Atta AM, Silva JPCG, Santiago MB, Oliveira IS, Oliveira RC, Sousa Atta MLB. Clinical and laboratory aspects of dyslipidemia in Brazilian women with systemic lupus erythematosus. Clin Rheumatol 2018. [DOI: 10.1007/s10067-018-4051-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
10
|
Nikpour M, Gladman DD, Urowitz MB. Premature coronary heart disease in systemic lupus erythematosus: what risk factors do we understand? Lupus 2014; 22:1243-50. [PMID: 24097996 DOI: 10.1177/0961203313493031] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coronary heart disease (CHD) is a major cause of mortality in systemic lupus erythematosus (SLE). This 'accelerated atherosclerosis' is due to a combination of traditional risk factors such as hypertension and hyperlipidemia, and also disease-related factors such as chronic inflammation. Recent work has provided valuable insights into the relative contribution of various risk factors and also identified novel risk factors. An understanding of risk factors is fundamental to the prevention of CHD in SLE. In this review, we will discuss the role of risk factors for CHD in SLE and offer some strategies for their assessment and management.
Collapse
Affiliation(s)
- M Nikpour
- 1University of Toronto Lupus Clinic and the Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Canada
| | | | | |
Collapse
|
11
|
Fernández-Nebro A, Marenco JL, López-Longo F, Galindo M, Hernández-Cruz BE, Narváez J, Rúa-Figueroa ÍI, Raya-Alvarez E, Zea A, Freire M, Sánchez-Atrio AI, García-Vicuña R, Pego-Reigosa JM, Manrique-Arija S, Nieves-Martín L, Carreño L. The effects of rituximab on the lipid profile of patients with active systemic lupus erythematosus: results from a nationwide cohort in Spain (LESIMAB). Lupus 2014; 23:1014-22. [DOI: 10.1177/0961203314534909] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Patients with systemic lupus erythematosus (SLE) have increased cardiovascular risk related to lipid changes induced by inflammatory activity, proteinuria and treatments. Our objective was to analyse lipid changes in a cohort of patients with SLE resistant to standard treatments who were treated with rituximab. Methods The study population comprised a retrospective multicentre, national cohort of patients with SLE resistant to standard treatments who were treated with rituximab. The basic lipid profile, concomitant treatment and disease activity were analysed at the start of the treatment, 24 weeks later, and at the end of the follow-up period. The effects of the main lupus variables and therapy on the lipid changes were analysed. Results Seventy-nine patients with active lupus treated with rituximab were assessed during 149.3 patient-years. Prior to the treatment, 69% had dyslipidaemia. The most frequent abnormalities were a low-density lipoprotein (LDL) level of ≥100 mg/dl (34%) and a high-density lipoprotein (HDL) level of <50 mg/dl (27%). Baseline total cholesterol (TC) and LDL levels correlated with the degree of proteinuria, while the concentration of triglycerides (TGs) correlated with the SLE Disease Activity Index (SLEDAI). TGs were reduced at short- and long-term follow-up after rituximab treatment. A multiple linear regression analysis identified that the reduction of the lupus inflammatory activity, particularly changes in proteinuria, was the only independent variable that was positively associated with the reduction in TGs after 24 weeks ( p = 0.001) and with TC ( p = 0.005) and TGs ( p < 0.001) at the end of the follow-up period. Conclusion Our results suggest that rituximab may improve the long-term lipid profile of patients with SLE refractory to standard treatment, mainly by reducing inflammatory activity.
Collapse
Affiliation(s)
- A Fernández-Nebro
- UGC Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga/Universidad de Málaga, Málaga, Spain
| | - JL Marenco
- Hospital Virgen de Valme, Rheumatology Department, Sevilla, Spain
| | - F López-Longo
- Hospital General Universitario Gregorio Marañón, Rheumatology Department, Madrid, Spain
| | - M Galindo
- Hospital Universitario 12 de Octubre, Rheumatology Department, Madrid, Spain
| | | | - J Narváez
- Hospital Universitario de Bellvitge, Rheumatology Department, Hospitalet de Llobregat, Barcelona, Spain
| | - Í I Rúa-Figueroa
- Hospital Universitario de Gran Canaria Dr Negrín, Rheumatology Department, Las Palmas de Gran Canaria, Spain
| | - E Raya-Alvarez
- Hospital Clínico Universitario San Cecilio, Rheumatology Department, Granada, Spain
| | - A Zea
- Hospital Universitario Ramón y Cajal, Rheumatology Department, Madrid, Spain
| | - M Freire
- Complejo Hospitalario Universitario A Coruña, Rheumatology Department, A Coruña, Spain
| | - AI Sánchez-Atrio
- Hospital Universitario Príncipe de Asturias, Rheumatology Department, Alcalá de Henares, Madrid, Spain
| | - R García-Vicuña
- Hospital Universitario de la Princesa, Rheumatology Department, Madrid, Spain
| | - JM Pego-Reigosa
- Complejo Hospitalario Universitario de Vigo, Rheumatology Department, Hospital del Mexoeiro, Instituto de Investigación Biomédica de Vigo (IBIV), Vigo, Spain
| | - S Manrique-Arija
- UGC Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga/Universidad de Málaga, Málaga, Spain
| | - L Nieves-Martín
- UGC Reumatología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga/Universidad de Málaga, Málaga, Spain
| | - L Carreño
- Hospital General Universitario Gregorio Marañón, Rheumatology Department, Madrid, Spain
| | | |
Collapse
|
12
|
|
13
|
Mancuso CA, Perna M, Sargent AB, Salmon JE. A pilot study of office-based spirometry in patients with systemic lupus erythematosus. Lupus 2012; 21:1343-50. [DOI: 10.1177/0961203312456750] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Although pulmonary involvement is common in systemic lupus erythematosus (SLE), its effects on healthy lifestyle physical activity and its association with fatigue have not been well characterized. The goals of this study were to describe pulmonary function measured by office-based spirometry in patients with SLE and to compare spirometry with physical activity and systemic fatigue. Methods: During an office visit, 49 patients with SLE completed spirometry assessing: a) forced expiratory volume in 1 s (FEV1, a measure of airway patency and responsiveness); b) forced vital capacity (FVC, a measure of lung volume); and c) maximum voluntary ventilation (MVV, a measure of volume of air moved during rapid breathing) which has been hypothesized to be decreased in SLE due to muscle fatigue. Patients also performed a 2-min corridor walking test and completed self-reported questionnaires measuring weekly physical activity and systemic fatigue. Results: Mean age was 45 years, 45 (92%) were women, mean SLEDAI and SLICC scores were 2.8 and 1.0, respectively. Some 24 patients had a smoking history, and 15 had a history of SLE-related pleuritis, which was not active at enrollment. FEV1 and FVC were 96% of predicted, but MVV was only 55% of predicted. The distance walked during the corridor test was similar to that of patients with other chronic diseases; however, self-reported physical activity was less than recommended by national guidelines. There were no associations between spirometry values and history of pleuritis, other pulmonary diagnoses, or smoking ( p > .10 for all comparisons), however, better FEV1 ( p = .04) and better FVC ( p = .04) were associated with more self-reported activity and better FEV1 ( p = .03) was associated with longer distance walked during the corridor test. Most patients reported marked systemic fatigue; however, there were no associations between spirometry values and fatigue scores ( p > .10 for all comparisons). Conclusions: MVV was markedly diminished, which supports the hypothesis that SLE may be associated with respiratory muscle fatigue during rapid breathing. MVV was not associated with mild-to-moderate patient-directed physical activity; however, lower FEV1 and FVC were associated with less self-reported and performance-based physical activity.
Collapse
Affiliation(s)
- CA Mancuso
- Research Division, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
| | - M Perna
- Research Division, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
| | - AB Sargent
- Research Division, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
| | - JE Salmon
- Research Division, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
| |
Collapse
|
14
|
Underdiagnosis and undertreatment of cardiovascular risk factors in patients with moderate to severe psoriasis. J Am Acad Dermatol 2012; 67:76-85. [DOI: 10.1016/j.jaad.2011.06.035] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 06/02/2011] [Accepted: 06/17/2011] [Indexed: 12/17/2022]
|
15
|
Eriksson K, Svenungsson E, Karreskog H, Gunnarsson I, Gustafsson J, Möller S, Pettersson S, Boström C. Physical activity in patients with systemic lupus erythematosus and matched controls. Scand J Rheumatol 2012; 41:290-7. [DOI: 10.3109/03009742.2011.624117] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
16
|
Bengtsson C, Bengtsson A, Costenbader K, Jönsen A, Rantapää-Dahlqvist S, Sturfelt G, Nived O. Systemic lupus erythematosus and cardiac risk factors: medical record documentation and patient adherence. Lupus 2011; 20:1057-62. [PMID: 21676919 DOI: 10.1177/0961203311403639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study explores patients' knowledge of cardiac risk factors (CRFs), analyses how information and advice about CRFs are documented in clinical practice, and assesses patient adherence to received instructions to decrease CRFs. Systemic lupus erythematosus (SLE) patients with ≥ 4 ACR criteria participated through completing a validated cardiovascular health questionnaire (CHQ). Kappa statistics were used to compare medical records with the self-reported CHQ (agreement) and to evaluate adherence. Two hundred and eleven (72%) of the known patients with SLE participated. The mean age of the patients was 55 years. More than 70% of the SLE patients considered hypertension, obesity, smoking and hypercholesterolaemia to be very important CRFs. The agreement between medical record documentation and patients' reports was moderate for hypertension, overweight and hypercholesterolaemia (kappa 0.42-0.60) but substantial for diabetes (kappa 0.66). Patients' self-reported adherence to advice they had received regarding medication was substantial to perfect (kappa 0.65-1.0). For lifestyle changes in patients with hypertension and overweight, adherence was only fair to moderate (kappa 0.13-0.47). Swedish SLE patients' awareness of traditional CRFs was good in this study. However, the agreement between patients' self-reports and medical record documentation of CRF profiles, and patients' adherence to medical advice to CRF profiles, could be improved.
Collapse
Affiliation(s)
- C Bengtsson
- Department of Rheumatology, Östersund Hospital, Sweden.
| | | | | | | | | | | | | |
Collapse
|
17
|
Saag KG, Yazdany J, Alexander C, Caplan L, Coblyn J, Desai SP, Harrington T, Liu J, McNiff K, Newman E, Olson R. Defining quality of care in rheumatology: the American College of Rheumatology white paper on quality measurement. Arthritis Care Res (Hoboken) 2011; 63:2-9. [PMID: 20945349 DOI: 10.1002/acr.20369] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Kenneth G Saag
- Division of Clinical Immunology & Rheumatology, University of Alabama, Birmingham, AL 35233, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Mancuso CA, Perna M, Sargent AB, Salmon JE. Perceptions and measurements of physical activity in patients with systemic lupus erythematosus. Lupus 2010; 20:231-42. [DOI: 10.1177/0961203310383737] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Promoting physical activity should be a priority for patients with systemic lupus erythematosus (SLE) because a sedentary lifestyle compounds patients’ already disproportionately high risk for cardiovascular events and other adverse health outcomes. The objectives of this pilot study were to assess physical activity in 50 patients with SLE and to compare activity levels with clinical and psychosocial variables, such as fatigue, depressive symptoms, and social support and stress. Patients were asked open-ended questions about physical activity, and responses were coded according to Grounded Theory. Patients then completed the Paffenbarger Physical Activity and Exercise Index, a survey of lifestyle energy expenditure reported in kilocalories/week, performed a 2-minute walk test according to a standard protocol, and completed questionnaires measuring fatigue, depressive symptoms and social support and stress. Most patients (92%) were women, had a mean age of 45 years, and did not have extensive SLE. In response to open-ended questions, patients reported they avoided physical activity because they did not want to exacerbate SLE in the short term. However, if they could overcome initial hurdles, 46 patients (92%) thought physical activity ultimately would improve SLE symptoms. Walking was the preferred activity and 45 (90%) thought they could walk more. According to the Paffenbarger Index, mean energy expenditure was 1466 ± 1366 kilocalories/week and mean time spent in moderate-intensity activity was 132 ± 222 min/week. In total, 18 patients (36%) and 14 patients (28%) met physical activity goals for these values, respectively. Mean distance walked during the 2-minute test was 149 ± 28 m, equivalent to two blocks, which is similar to reports for stable patients with other chronic diseases. Patients with more social stress and more fatigue reported less physical activity. We conclude that the proportion of patients meeting physical activity goals was low; however, patients performed well on a standard walking test. Most patients believed physical activity provided long-term benefits for SLE and that they could be more physically active.
Collapse
Affiliation(s)
- CA Mancuso
- Research Division and Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
| | - M Perna
- Research Division, Hospital for Special Surgery, New York, USA
| | - AB Sargent
- Research Division, Hospital for Special Surgery, New York, USA
| | - JE Salmon
- Research Division and Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, New York, USA
| |
Collapse
|
19
|
Maksimowicz-McKinnon K, Selzer F, Manzi S, Kip KE, Mulukutla SR, Marroquin OC, Smitherman TC, Kuller LH, Williams DO, Wasko MCM. Poor 1-year outcomes after percutaneous coronary interventions in systemic lupus erythematosus: report from the National Heart, Lung, and Blood Institute Dynamic Registry. Circ Cardiovasc Interv 2010; 1:201-8. [PMID: 20031679 DOI: 10.1161/circinterventions.108.788745] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Women with systemic lupus erythematosus (SLE) have premature and accelerated atherosclerosis. Although percutaneous coronary intervention (PCI) is used frequently to treat coronary artery disease in SLE, little is known regarding PCI outcomes immediately after PCI and after discharge. METHODS AND RESULTS Baseline demographic, procedure-related, and adverse outcome data on consecutive patients undergoing PCI during 5 recruitment "waves" of the National Heart, Lung, and Blood Institute Dynamic Registry across 23 clinical centers were collected. SLE patients (n=28) were compared with non-SLE patients (n=3385). SLE patients were younger and more often female in comparison with non-SLE patients undergoing PCI. SLE patients were less likely than non-SLE patients to have hyperlipidemia but had a similar prevalence of hypertension, diabetes mellitus, and tobacco use. The prevalence of multivessel disease was similar between groups. Initial intervention success (by angiographic definition) was not significantly different between groups. At 1 year, SLE patients were more likely to experience a myocardial infarction (15.6% versus 4.8%, P=0.01) and more often required repeat PCI (31.3% versus 11.8%, P=0.009) than non-SLE patients, even after adjustment for important covariates. CONCLUSIONS SLE patients had significantly worse cardiovascular outcomes at 1 year than non-SLE patients. Even considering the small number of SLE patients, these differences were striking. Further study is warranted to explore other factors potentially accounting for this disparity, including SLE disease activity and duration, presence of hypercoagulable state, and immunosuppressive therapy.
Collapse
Affiliation(s)
- Kathleen Maksimowicz-McKinnon
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh School of Medicine, 3500 Terrace Street, Pittsburgh, PA 15213, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Skamra C, Ramsey-Goldman R. Management of cardiovascular complications in systemic lupus erythematosus. ACTA ACUST UNITED AC 2010; 5:75-100. [PMID: 20305727 DOI: 10.2217/ijr.09.73] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Patients with SLE have an excess risk compared with the general population; this is particularly pronounced in younger women with SLE who have an excess risk of over 50-fold compared with population controls. There is a higher prevalence of subclinical atherosclerosis in patients with SLE compared with controls, as demonstrated by a variety of imaging modalities discussed in this review. The causality of the excess risk of CVD and subclinical atherosclerosis is multifactorial in patients with SLE. While traditional risk factors play a role, after controlling for the traditional Framingham risk factors, the excess risk is still 7.5-fold greater than the general population. This review will also cover novel cardiovascular risk factors and some SLE-specific variables that contribute to CVD risk. This review discusses the risk factor modification and the evidence available for treatment of these risk factors in SLE. There have not yet been any published randomized, controlled trials in patients with SLE with respect to CVD risk factor modifications. Thus, the treatment and management recommendations are based largely on published guidelines for other populations at high risk for CVD.
Collapse
|
21
|
Shah MA, Shah AM, Krishnan E. Poor outcomes after acute myocardial infarction in systemic lupus erythematosus. J Rheumatol 2009; 36:570-5. [PMID: 19208594 DOI: 10.3899/jrheum.080373] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Systemic lupus erythematosus (SLE) is associated with higher risk for acute myocardial infarction (MI); but the post-infarction outcomes among these patients are unknown. Our objective was to compare post-acute MI outcomes in patients with SLE to those with diabetes mellitus (DM) and those with neither condition. METHODS We analyzed the risk for prolonged hospitalization and in-hospital mortality following acute MI in the 1993-2002 US Nationwide Inpatient Sample. We used logistic regression to calculate odds ratios (OR) for prolonged hospitalization and Cox proportional hazards regression to calculate hazard ratios (HR) for in-hospital mortality with and without adjustments for age, sex, race/ethnicity, socioeconomic status, and presence of congestive heart failure. RESULTS For the SLE (n = 2192), DM (n = 236,016), SLE/DM (n = 474), and control (n = 667,956) groups, the in-hospital mortality rates were 8.3%, 6.2%, 5.7%, and 4.7%, respectively. In multivariable regression models, all 3 disease groups had higher adverse outcome risk compared to control. The OR for prolonged hospitalization was higher for those with SLE (OR 1.48, 95% CI 1.32-1.79) compared to those with DM (OR 1.30, 95% CI 1.28-1.32). A similar pattern was observed for hazard ratios for in-hospital mortality as well (SLE, HR 1.65, 95% CI 1.33-2.04; DM, HR 1.11, 95% CI 1.07-1.14). CONCLUSION SLE, like DM, increases risk of poor outcomes after acute MI. These patients need to be triaged appropriately for aggressive care.
Collapse
Affiliation(s)
- Mansi A Shah
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky, USA
| | | | | |
Collapse
|
22
|
Sandborg C, Ardoin SP, Schanberg L. Therapy Insight: cardiovascular disease in pediatric systemic lupus erythematosus. ACTA ACUST UNITED AC 2008; 4:258-65. [PMID: 18349862 DOI: 10.1038/ncprheum0789] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 02/11/2008] [Indexed: 12/31/2022]
Abstract
In 15-20% of cases, systemic lupus erythematosus (SLE) presents before the age of 18 years, and such early-onset SLE seems to be particularly severe. SLE is an independent risk factor for premature atherosclerosis and death in young, premenopausal women with SLE, even after controlling for traditional cardiovascular risk factors. Children and adolescents with SLE are particularly susceptible to this long-term threat to their cardiovascular health because they have an increased disease severity and a lengthy disease burden. Factors that contribute to premature atherosclerosis include the inflammatory and immune abnormalities that are intrinsic to SLE, primary dyslipidemias, and the secondary effects of treatments such as corticosteroids. However, few rheumatologists provide appropriate preventive or management strategies for the increased atherosclerosis risk in this age-group. Screening should be performed on a regular basis, including evaluation of, and counseling for, traditional risk factors. Studies of treatment in pediatric patients are limited, and treatment strategies are often extrapolated from adult studies. Statins hold promise because they have both lipid-lowering and anti-inflammatory effects. There have been few studies of the use of statins in adults or adolescents with SLE; however, trials are currently underway to address the safety and efficacy of statin use in pediatric SLE.
Collapse
Affiliation(s)
- Christy Sandborg
- Division of Pediatric Rheumatology, Stanford University School of Medicine, 300 Pasteur Drive, Room A085, Stanford, CA 94305, USA.
| | | | | |
Collapse
|
23
|
Ardoin SP, Sandborg C, Schanberg LE. Management of dyslipidemia in children and adolescents with systemic lupus erythematosus. Lupus 2008; 16:618-26. [PMID: 17711898 DOI: 10.1177/0961203307079566] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Systemic lupus erythematosus (SLE) is an independent risk factor for atherosclerosis, placing children and adolescents with SLE at great risk for developing cardiovascular sequelae, including myocardial infarction, in adulthood. Dyslipidemia and other traditional cardiac risk factors occur frequently in pediatric SLE and are often under-recognized and under-treated. Two dyslipidemia patterns are evident in pediatric SLE. Active disease is characterized by elevated triglycerides (TG) and low high density lipoprotein (HDL). With SLE treatment HDL and TG often normalize, while total cholesterol and low density lipoprotein (LDL) rise. The complex pathophysiology of dyslipidemia in SLE involves cytokines, autoantibodies, disease activity, medications, diet, and physical activity level, as well as other factors. Routine screening for dyslipidemia with fasting lipid profiles is indicated for children and adolescents with SLE. If lipoprotein levels are abnormal, first line therapy involves diet and exercise interventions for a minimum of six months. For persistent dyslipidemia, several pharmacologic therapies are available. Hydroxychloroquine, a common treatment for SLE, can improve lipid profiles and should be considered for all patients with SLE. Statins and bile acid sequestrants are typically added first for dyslipidemia, while niacin and fibrates are reserved for refractory disease and optimally prescribed in a multidisciplinary lipid clinic. Future research is needed to further illuminate the mechanisms of dyslipidemia in pediatric SLE with well designed clinical trials to determine the safest and most effective interventions to correct lipid profiles and prevent atherosclerosis.
Collapse
Affiliation(s)
- S P Ardoin
- Department of Pediatrics, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | |
Collapse
|
24
|
Scalzi LV, Ballou SP, Park JY, Redline S, Kirchner HL. Cardiovascular disease risk awareness in systemic lupus erythematosus patients. ACTA ACUST UNITED AC 2008; 58:1458-64. [DOI: 10.1002/art.23419] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
25
|
Chung CP, Avalos I, Raggi P, Stein CM. Atherosclerosis and inflammation: insights from rheumatoid arthritis. Clin Rheumatol 2007; 26:1228-33. [PMID: 17273810 DOI: 10.1007/s10067-007-0548-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Accepted: 01/13/2007] [Indexed: 10/23/2022]
Abstract
Cardiovascular disease is a major health care problem and the most common cause of death among individuals from developed nations. Our understanding of atherosclerosis has evolved from a passive process resulting in narrowing of the lumen and consequent myocardial ischemia to a dynamic process that involves inflammation. The study of atherosclerosis in patients with chronic inflammation, such as rheumatoid arthritis (RA), will provide insights into the relationship between inflammation and atherosclerosis. We review the relationship between atherosclerosis and inflammation within the context of RA, providing evidence that patients with RA have increased cardiovascular morbidity and mortality and accelerated coronary and extra-coronary atherosclerosis. In addition, traditional and novel cardiovascular risk factors are discussed. Finally, actions that a rheumatologist can take to better control this cardiovascular morbidity are suggested. These can be summarized as follows: (1) careful assessment and treatment of cardiovascular risk, (2) better control of inflammation, and (3) individual risk-benefit evaluation of need for cyclo-oxygenase-2 inhibitors, nonsteroidal anti-inflammatory drugs, and high doses of corticosteroids.
Collapse
Affiliation(s)
- Cecilia P Chung
- Division of Rheumatology, Department of Medicine, Vanderbilt University, 1161 21st Avenue T-3219 MCN, Nashville, TN 37232, USA.
| | | | | | | |
Collapse
|
26
|
Domsic R, Maksimowicz-McKinnon K, Manzi S. Prevention of cardiovascular disease in patients with rheumatic diseases. Best Pract Res Clin Rheumatol 2006; 20:741-56. [PMID: 16979536 DOI: 10.1016/j.berh.2006.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cardiovascular disease (CVD), the leading cause of death in the USA, has emerged as an important comorbidity in the rheumatic diseases. As disease-modifying therapies have resulted in better disease control and decreases in disease-associated mortality, it is now apparent that the prevalence of CVD and cardiovascular (CV) events is significantly increased in a number of rheumatic disorders when compared with age and gender-matched subjects from the general population. Investigations into the mechanisms of CVD in the general population have provided insights into potential mechanisms in rheumatic disease patients and possible aetiologies for their increased risk. Although there are no evidence-based guidelines for CV risk factor screening and interventions specific to patients with rheumatic disease, the best current approach utilizes evidence-based recommendations for the general population (and higher-risk subgroups) modified by what is known of CV risk factor and event prevalence in these patients.
Collapse
Affiliation(s)
- Robyn Domsic
- University of Pittsburgh, Division of Rheumatology and Clinical Immunology, Pittsburgh, PA 15261, USA
| | | | | |
Collapse
|
27
|
Costenbader KH, Karlson EW, Gall V, de Pablo P, Finckh A, Lynch M, Bermas B, Schur PH, Liang MH. Barriers to a trial of atherosclerosis prevention in systemic lupus erythematosus. ACTA ACUST UNITED AC 2005; 53:718-23. [PMID: 16208639 DOI: 10.1002/art.21441] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The effectiveness of aggressive management of traditional risk factors for accelerated atherosclerosis in systemic lupus erythematosus (SLE) has been advocated but not proven. We conducted a pilot, randomized, controlled trial of known prevention medications (pravastatin, ramipril, aspirin, and a combination B vitamin) plus individualized cardiovascular prevention education. We describe our experience in recruiting and retaining patients with SLE in this trial. METHODS Patients with SLE by American College of Rheumatology criteria who lived within 1 hour of the hospital and had visits within the past 3 years were screened. All eligible patients were contacted by the principal investigator who was not their physician. The reasons for nonparticipation were elicited in a nonjudgmental manner. RESULTS A total of 662 patients met the selection criteria for the study. Of these, 295 patients (45%) with contraindications to study medications were excluded. Ninety-seven (40%) of 244 eligible patients refused to participate. More than 40% of those phoned were unwilling to participate and, among those, 19% felt they were too sick, too well, or taking too many medications already. A total of 41 patients were enrolled in the trial, and 22 dropped out within 4 months. CONCLUSION SLE is a chronic disease, and the development and testing of interventions aimed at the prevention of long-term sequelae are of paramount importance. Prevention trials in SLE face serious challenges, including the recruitment and retention of participants. Our experience provides insights into the barriers to participation in randomized prevention trials in SLE.
Collapse
|