Disability in valued life activities among individuals with systemic lupus erythematosus

Comparison of two frailty definitions in women with systemic lupus erythematosus

OBJECTIVES

Frailty is a risk factor for adverse health in SLE. The Fried phenotype (FP) and the SLICC Frailty Index (SLICC-FI) are common frailty metrics reflecting distinct approaches to frailty assessment. We aimed to (1) compare frailty prevalence according to both metrics in women with SLE and describe differences between frail and non-frail participants using each method and (2) evaluate for cross-sectional associations between each metric and self-reported disability.

METHODS

Women aged 18-70 years with SLE were enrolled. FP and SLICC-FI were measured, and agreement calculated using a kappa statistic. Physician-reported disease activity and damage, Patient Reported Outcome Measurement Information System (PROMIS) computerized adaptive tests, and Valued Life Activities (VLA) self-reported disability were assessed. Differences between frail and non-frail participants were evaluated cross-sectionally, and the association of frailty with disability was determined for both metrics.

RESULTS

Of 67 participants, 17.9% (FP) and 26.9% (SLICC-FI) were frail according to each metric (kappa = 0.41, P < 0.01). Compared with non-frail women, frail women had greater disease damage, worse PROMIS scores, and greater disability (all P < 0.01 for FP and SLICC-FI). After age adjustment, frailty remained associated with a greater odds of disability [FP: odds ratio (OR) 4.7, 95% CI 1.2, 18.8; SLICC-FI: OR 4.6, 95% CI 1.3, 15.8].

CONCLUSION

Frailty is present in 17.9-26.9% of women with SLE. These metrics identified a similar, but non-identical group of women as frail. Further studies are needed to explore which metric is most informative in this population.

The Effects of Systemic Lupus-Related Cognitive Impairments on Activities of Daily Living and Life Role Participation: A Qualitative Framework Study

OBJECTIVE

Cognitive impairment (CI) in systemic lupus erythematosus (SLE) negatively impacts health-related quality of life leading to activity limitations. This qualitative study aimed to (1) explore the effect of SLE-related CI on activities of daily living and life role participation and (2) describe factors influencing activity restriction and life role participation.

METHODS

Semistructured, in-depth interviews of lived experience of CI in SLE were conducted with 24 participants with SLE. Sociodemographic and clinical data, and objective and subjective cognitive function, were collected to characterize participants. A qualitative thematic content analysis was undertaken guided by a framework analytical approach.

RESULTS

Participants reported problems in multiple cognitive domains, with multiple perceived causes. CI was felt to impact work, social, domestic, and family life, health, and independence. Five overarching themes were represented in the data: (1) characterization of SLE-reported CI, (2) perceived cause of CI, (3) perceived impact of CI on activities of daily living and life role participation, (4) adaptations for managing CI, and (5) influence of CI adaptations on activities of daily living and life role participation.

CONCLUSION

This study provides a better understanding of the patient experience of CI in SLE, how it impacts their lives, and what coping strategies they employ. It highlights the long-term challenges those with CI in SLE undergo and provides evidence for the urgent need to implement multidisciplinary treatment options. When managing CI, it may be beneficial to evaluate and understand available psychosocial support resources to help identify and reinforce relevant adaptations to improve health-related quality of life.

Longitudinal mediation effects of activity meaning on the association between activity performance and quality of life among older adults with disabilities

BACKGROUND

Physical limitations may hinder older adults with physical disabilities' capability to perform various activities, which can affect their quality of life (QOL). Accomplishing meaningful activities may mitigate the impact of limited activity performance on their QOL. This longitudinal study aims to investigate how activity meaning mediates the relationship between activity performance and QOL among older adults with disabilities.

METHODS

Data for this longitudinal study was collected from 813 community-dwelling older adults aged 60 and above who had physical disabilities, over a two year interval. Path analysis was used to examine the cross-sectional and longitudinal mediation effects from activity performance, through activity meaning, to QOL.

RESULTS

At the same wave, high IADL performance or social activity performance, and high QOL was indirectly associated through high IADL meaning or social meaning. As for longitudinal association, high T1 IADL performance was associated with better T2 QOL through high T1 and T2 IADL meaning. Similarly, high T1 social activity performance also contributed to T2 QOL through high T1 and T2 social activity meaning. Additionally, social activity performance exhibited higher influence on QOL than that of IADL.

CONCLUSIONS

Both IADL and social activities have distinct impacts on the QOL of older adults with disabilities. To improve the current and future QOL of older adults with disabilities, professionals must prioritize their involvement in the most meaningful activities while being sensitive to and supportive of their preferences and valued lifestyles.

Importance and difficulty with valued life activities for people with systemic sclerosis

PURPOSE

To identify the importance of and difficulty with valued activities in persons with systemic sclerosis (SSc) and to examine relationships between disease symptoms and difficulty with valued activities using the Valued Activities Scale (VLA). A secondary purpose was to examine the internal consistency of the Short-VLA Scale (S-VLA).

METHODS

A cross-sectional convenience sample of 99 people with SSc completed questionnaires regarding demographics, symptom severity, Health Assessment Questionnaire (HAQ), Center for Epidemiologic Studies Depression Scale (CES-D), and the VLA.

RESULTS

Obligatory activities were rated as most important; committed activities were significantly more difficult than obligatory and discretionary. Less fatigue (p < 0.01) and lower HAQ (p < 0.001) and CES-D (p < 0.01) scores were associated with higher total VLA scores. Internal consistency of the S-VLA was excellent (Cronbach's alpha = 0.92; p < 0.0001). The correlation between the S-VLA and the VLA was excellent (r = 0.96; p < 0.001). There were moderate correlations between the S-VLA and the HAQ (r = 0.73; p < 0.0001); the correlation with the CES-D was only fair (r = 0.35; p < 0.001).

CONCLUSIONS

Committed and discretionary activities were more difficult for people with SSc to perform. Results are similar to findings with people with rheumatoid arthritis and systemic lupus erythematosus.IMPLICATIONS FOR REHABILITATIONHome management/caregiving (committed) and leisure and social participation (discretionary) activities are more difficult to perform by people with SSc compared to self-care (obligatory) activities.Our findings that difficulty scores on the VLA were associated with more fatigue and depression suggest the need for rehabilitation to reduce disability in people with SSc.The S-VLA may be a useful screening and monitoring tool for SSc and other chronic conditions.

Association of Baseline Frailty with Patient-Reported Outcomes in Systemic Lupus Erythematosus at 1 Year

The relationship of baseline frailty with subsequent patient-reported outcomes in systemic lupus erythematosus (SLE) remains unclear. We assessed these associations in a pilot prospective cohort study. Frailty based on the FRAIL scale and the Fried phenotype and patient-reported outcomes, namely Patient Reported Outcomes Measurement Information System computerized adaptive tests and Valued Life Activities disability, were measured at baseline and 1 year among women aged 18-70 years with SLE enrolled at a single center. Differences in Patient Reported Outcomes Measurement Information System computerized adaptive tests between frail and non-frail participants were evaluated using Wilcoxon rank sum tests, and the association of baseline frailty with self-report disability at 1 year was estimated using linear regression. Of 51 participants, 24% (FRAIL scale) and 16% (Fried phenotype) met criteria for frailty at baseline despite median age of 55.0 and 56.0 years, respectively. Women with (versus without) baseline frailty using either measure had worse 1-year Patient Reported Outcomes Measurement Information System computerized adaptive test scores across multiple domains and greater self-report disability. Baseline frailty was significantly associated with self-report disability at 1 year (FRAIL scale: parameter estimate 0.55, 95% confidence interval (CI) 0.21-0.89, p<0.01; Fried phenotype: parameter estimate 0.61, 95% CI 0.22-1.00, p<0.01), including only slight attenuation after adjustment for SLE cumulative organ damage (FRAIL scale: parameter estimate 0.45, 95% CI 0.09-0.81, p=0.02; Fried phenotype: parameter estimate 0.49, 95% CI 0.09-0.90, p=0.02). These preliminary findings support frailty as an independent risk factor for clinically relevant patient-reported outcomes, including disability onset, among women with SLE.

Patient Experiences of Systemic Lupus Erythematosus: Findings From a Systematic Review, Meta-Summary, and Meta-Synthesis

OBJECTIVE

To explore the experience of patients with systemic lupus erythematosus (SLE).

METHODS

A systematic review of qualitative studies published in English in the past 10 years and identified through the PubMed, CINAHL, Scopus, and Web of Science databases was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The methodologic quality of each included study was assessed using the Critical Appraisal Screening Programme tool. Study findings were then subjected to a meta-summary and meta-synthesis.

RESULTS

Twenty-six studies with a good overall methodologic quality were included, documenting the experience of 565 adult patients (95% women). A total of 17 codes emerged, summarizing the life experience of SLE patients; the most and least frequent codes in the meta-summary were "feeling not as I usually do" (69.2%) and "having wishes" (7.7%). The codes were then categorized into 5 main themes, summarizing the experience of living with SLE: 1) "experiencing waves of emotions due to the unpredictable nature of the disease," 2) "trying to live an ordinary life," 3) "listening to and obeying the body's limitations," 4) "reviewing my life projects," and 5) "dealing with future uncertainties."

CONCLUSION

Several qualitative studies have been published to date using good methodologic approaches. According to the findings, SLE negatively impacts patient experiences by affecting multiple dimensions of their daily lives, with fatigue and pain as the most frequent symptoms.

Generation of evidence supporting the content validity of SF-36, FACIT-F, and LupusQoL, and novel patient-reported symptom items for use in patients with systemic lupus erythematosus (SLE) and SLE with lupus nephritis (LN)

OBJECTIVE

SLE and lupus nephritis (LN) have significant impacts on the health-related quality of life of patients living with the condition, which are important to capture from the patient's perspective using patient-reported outcomes (PROs). The objectives of this study were to evaluate the content validity of PROs commonly used in SLE and LN (36-Item Short Form Health Survey (SF-36), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and Lupus Quality of Life (LupusQoL), as well as novel PRO symptom severity items measuring skin rash, joint pain, joint stiffness and swelling of the legs and/or feet, in both populations.

METHODS

Qualitative, semi-structured, cognitive interviews were conducted with 48 participants (SLE=28, LN=20). Understanding and relevance of symptom and impact PRO concepts from existing PROs were assessed, alongside novel PRO symptom severity items with different recall periods (24 hours vs 7 days) and response scales (Numerical Rating Scale (NRS) vs Verbal Rating Scale). Interviews were conducted in multiple rounds to allow for modifications to the novel PRO items. Analysis of verbatim interview transcripts was performed.

RESULTS

Symptom and impact concepts assessed by the SF-36, FACIT-F, and LupusQoL were well understood by both participants with SLE and LN (≥90.0%), with most considered relevant by over half of the participants asked (≥51.9%). All participants asked (100%) understood the novel PRO symptom severity items, and the majority (≥90.0%) considered the symptoms relevant. Minor modifications to the novel PRO items were made between rounds to improve clarity based on participant feedback. The selected 7-day recall period and NRS in the final iteration of the PRO items were understood and relevant. No differences in interview findings between the SLE and LN samples were identified.

CONCLUSIONS

Findings provide evidence of content validity for concepts assessed by the SF-36, FACIT-F, LupusQoL and the novel PRO symptom severity items, supporting use of these PROs to comprehensively assess disease impact in future SLE and LN clinical trials.

Establishing the Minimal Clinically Important Difference and Substantial Clinical Benefit for the Pain Visual Analog Scale in a Postoperative Hand Surgery Population

PURPOSE

Although the pain visual analog scale (VAS-pain) is a ubiquitous patient-reported outcome instrument, it remains unclear how to interpret changes or differences in scores. Therefore, our purpose was to calculate the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

METHODS

Adult postoperative patients treated by 1 of 5 fellowship-trained orthopedic hand surgeons at a single tertiary academic medical center were identified. Inclusion required VAS-pain scores at baseline (up to 3 months before surgery) and follow-up (up to 4 months after surgery), in addition to a response to a pain-specific anchor question at follow-up. The MCID estimates were calculated with (1) the 1/2 standard deviation method; and (2) an anchor-based approach. The SCB estimates were calculated with (1) an anchor-based approach; and (2) a receiver operator curve method that maximized the sensitivity and specificity for detecting a "much improved" pain status.

RESULTS

There were 667 and 148 total patients included in the MCID and SCB analyses, respectively. The 1/2 standard deviation MCID estimate was 1.6, and the anchor-based estimate was 1.9. The anchor-based SCB estimate was 2.2. The receiver operator curve analysis yielded an SCB estimate of 2.6, with an area under the curve of 0.72, consistent with acceptable discrimination.

CONCLUSIONS

We propose MCID values in the range of 1.6 to 1.9 and SCB values in the range of 2.2 to 2.6 for the VAS-pain instrument in a nonshoulder hand and upper extremity postoperative population.

CLINICAL RELEVANCE

These MCID and SCB estimates may be useful for powering clinical studies and when interpreting VAS-pain score changes or differences reported in the hand surgery literature. These values are to be applied at a population level, and should not be applied to assess the improvement, or lack thereof, for individual patients.

Longitudinal changes in cardiac function in Duchenne muscular dystrophy population as measured by magnetic resonance imaging

BACKGROUND

The lack of dystrophin in cardiomyocytes in Duchenne muscular dystrophy (DMD) is associated with progressive decline in cardiac function eventually leading to death by 20-40 years of age. The aim of this prospective study was to determine rate of progressive decline in left ventricular (LV) function in Duchenne muscular dystrophy (DMD) over 5 years.

METHODS

Short axis cine and grid tagged images of the LV were acquired in individuals with DMD (n = 59; age = 5.3-18.0 years) yearly, and healthy controls at baseline (n = 16, age = 6.0-18.3 years) on a 3 T MRI scanner. Grid-tagged images were analyzed for composite circumferential strain (ℇcc%) and ℇcc% in six mid LV segments. Cine images were analyzed for left ventricular ejection fraction (LVEF), LV mass (LVM), end-diastolic volume (EDV), end-systolic volume (ESV), LV atrioventricular plane displacement (LVAPD), and circumferential uniformity ratio estimate (CURE). LVM, EDV, and ESV were normalized to body surface area for a normalized index of LVM (LVMI), EDV (EDVI) and ESV (ESVI).

RESULTS

At baseline, LV ℇcc% was significantly worse in DMD compared to controls and five of the six mid LV segments demonstrated abnormal strain in DMD. Longitudinal measurements revealed that ℇcc% consistently declined in individuals with DMD with the inferior segments being more affected. LVEF progressively declined between 3 to 5 years post baseline visit. In a multivariate analysis, the use of cardioprotective drugs trended towards positively impacting cardiac measures while loss of ambulation and baseline age were associated with negative impact. Eight out of 17 cardiac parameters reached a minimal clinically important difference with a threshold of 1/3 standard deviation.

CONCLUSION

The study shows a worsening of circumferential strain in dystrophic myocardium. The findings emphasize the significance of early and longitudinal assessment of cardiac function in DMD and identify early biomarkers of cardiac dysfunction to help design clinical trials to mitigate cardiac pathology. This study provides valuable non-invasive and non-contrast based natural history data of cardiac changes which can be used to design clinical trials or interpret the results of current trials aimed at mitigating the effects of decreased cardiac function in DMD.

The minimal clinically important difference of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function and upper extremity computer adaptive tests and QuickDASH in the setting of elbow trauma

Background

Minimal clinically important difference (MCID) estimates are useful for gauging clinical relevance when interpreting changes or differences in patient-reported outcomes scores. These values are lacking in the setting of elbow trauma. Our primary purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) computer adaptive test (CAT), the PROMIS upper extremity (UE) CAT, and the QuickDASH using an anchor-based approach for patients recovering from elbow trauma and related surgeries. Secondarily, we aimed to estimate the MCID using the 1/2 standard deviation method.

Materials & methods

Adult patients undergoing treatment for isolated elbow injuries between July 2014 and April 2020 were identified at a single tertiary academic medical center. Outcomes, including the PROMIS PF CAT v1.2/2.0, PROMIS UE CAT v1.2, and QuickDASH, were collected via a tablet computer. For inclusion, baseline (6 months before injury up to 11 days postoperatively or after injury) and follow-up (11 to 150 days postoperative or after injury) PF or UE CAT scores were required, as well as a response to an anchor question querying improvement in physical function. The MCID was calculated using (1) an anchor-based approach using the difference in mean score change between anchor groups reporting “No change” and “Slightly Improved/Improved” and (2) the 1/2 standard deviation method.

Results

Of the 146 included patients, the mean age was 46 ± 18 years and 67 (46%) were women. Most patients (129 of 146 or 88%) were recovering from surgery, and the remaining 12% were recovering from nonoperatively managed fractures and/or dislocations. The mean follow-up was 157 ± 192 days. Scores for each instrument improved significantly between baseline and follow-up. Anchor-based MCID values were calculated as follows: 5.7, 4.6, and 5.3 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively. MCID values estimated using the 1/2 standard deviation method were 4.3, 4.8, and 11.7 for the PROMIS PF CAT, PROMIS UE CAT, and QuickDASH, respectively.

Conclusions

In the setting of elbow trauma, we propose MCID ranges of 4.3 to 5.7 for the PROMIS PF CAT, 4.6 to 4.8 for the PROMIS UE CAT, and 5.3 to 11.7 for the QuickDASH. These values will provide a framework for clinical relevance when interpreting clinical outcomes studies, or powering clinical trials, for populations recovering from trauma.

Establishing the Minimal Clinically Important Difference for the PROMIS Upper Extremity Computer Adaptive Test Version 2.0 in a Nonshoulder Hand and Upper Extremity Population

PURPOSE

Our primary purpose was to calculate the minimal clinically important difference (MCID) for the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) Computer Adaptive Test (CAT) version 2.0 (v2.0) for a nonshoulder hand and upper extremity population. Secondarily, we calculated the PROMIS Physical Function (PF) CAT v2.0 and the abbreviated version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) MCID.

METHODS

Adult patients treated by 1 of 5 fellowship-trained hand surgeons between March 2015 and September 2019 at an academic tertiary institution were identified. The PROMIS UE CAT v2.0, PROMIS PF CAT v2.0, and QuickDASH were collected via tablet computer. Inclusion required response to at least 1 of the instruments at both baseline and follow-up (6 ± 4 weeks), and a response to the anchor question: "Compared to your first evaluation at the University Orthopaedic Center, how would you describe your physical function level now?" An additional anchor question assessing treatment-related improvement was also asked. The MCID was calculated using an anchor-based approach using the mean change difference between groups reporting no change and slight change for both anchor questions, and with the 1/2 SD method.

RESULTS

Of 2,106 participants, mean age was 48 ± 17 years, 53% were female, and 53% were recovering from surgery. Of these patients, 381 completed the PROMISE UE CAT v2.0, 497 completed the PROMIS PF CAT v2.0, and 2,018 completed the QuickDASH. The score change between baseline and follow-up was significantly different between anchor groups for both anchor-based MCID calculations. Anchor-based MCID values were 3.0 to 4.0 for the UE CAT, 2.1 to 3.6 for the PF CAT, and 10.3 for the QuickDASH. The MCID values per the 1/2 SD method were 4.1, 4.1, and 10.2, respectively.

CONCLUSIONS

We propose MCID ranges of 3.0 to 4.1 for the PROMIS UE CAT v2.0, and 2.1 to 4.1 for the PROMIS PF CAT v2.0. The observed QuickDASH MCID values (10.2-10.3) are within the range of previously published values.

CLINICAL RELEVANCE

These MCID estimates will aid in interpreting clinical outcomes and in powering clinical studies.

Impaired hand function and performance in activities of daily living in systemic lupus erythematosus, even in patients achieving lupus low disease activity state (LLDAS)

Objective

The aim was to examine hand function and performance in activities of daily living (ADL) in patients with SLE vs healthy controls, and any associations with demographic and disease-related characteristics.

Methods

Hand function (grip strength, pinch strength and dexterity) and ADL performance were evaluated in 240 patients with SLE and 122 age- and biological sex-matched healthy controls. Grip strength, pinch strength and dexterity were measured by Jamar dynamometer, pinch gauge and Purdue pegboard test, respectively. Self-reported ADL performance was assessed by disabilities of the arm, shoulder and hand (DASH) and HAQ. Regression analysis was performed to assess the determinants of hand dysfunction.

Results

All hand function and ADL performance variables were significantly impaired in the entire SLE cohort and the subgroup of patients achieving lupus low disease activity state (LLDAS; n = 157) compared with healthy subjects (P < 0.05). Joint pain, often underestimated in SLE, was the major determinant of hand function and ADL performance in multiple regression models. In addition, age was correlated with grip strength and Purdue scores, gender with grip strength, arthritis with DASH and HAQ, and use of immunosuppressives with DASH, HAQ and grip strength. Likewise, in patients in LLDAS, painful joints were correlated with DASH and HAQ, age with grip strength and Purdue (P < 0.001), gender with grip strength, and immunosuppressives with HAQ and grip strength.

Conclusion

Hand function and performance of daily activities are significantly impaired in SLE, even in patients who achieve LLDAS, suggesting the need for their evaluation and management in clinical practice.

Evaluation of a Patient-reported Frailty Tool in Women With Systemic Lupus Erythematosus

OBJECTIVE

Frailty is associated with mortality in systemic lupus erythematosus (SLE), but how best to measure frailty is unclear. We aimed to compare 2 frailty metrics, the self-reported Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight (FRAIL) scale (FS) and the Fried phenotype (FP), in SLE to evaluate differences between frail and nonfrail women and whether frailty is associated with self-reported disability.

METHODS

Adult women aged < 70 years with validated SLE and mild/moderate disease enrolled in this cross-sectional study between August 2018 and October 2019. Correlation and agreement between the FS and the FP were determined. Differences in sociodemographic and disease characteristics, patient-reported outcome measures (PROMs), and biomarkers between frail and nonfrail participants were evaluated, as well as the association of frailty with Valued Life Activities disability.

RESULTS

Of 67 participants, 27% and 18% were frail according to the FS and the FP, respectively. Correlation (r = 0.51; P < 0.0001) and agreement (κ = 0.46; P = 0.0004) between the FS and the FP were significant. Frail women had greater disease damage, high-sensitivity C-reactive protein, and interleukin 6, and worse PROMs according to both frailty definitions. Both frailty measures were associated with self-reported disability after adjustment for age, comorbidity, and disease activity and damage; this relationship was attenuated for the FP.

CONCLUSION

Frailty prevalence was high in this cohort of women with SLE using both frailty definitions, suggesting that frailty may be accelerated in women with SLE, particularly when based exclusively on self-report. Frailty remained associated with self-reported disability in adjusted analyses. The FS may be an informative point-of-care tool to identify frail women with SLE.

The Relationship of Lifestyle with Disease Activity among Patients with Systemic Lupus Erythematosus: A Descriptive-Correlational Study

Objective:

The objective of this study was to evaluate the relationship of lifestyle with disease activity among patients with systemic lupus erythematosus.

Methods:

This cross-sectional descriptive-correlational study was conducted in 2019 on 209 patients with systemic lupus erythematosus. Data were collected using a demographic and clinical characteristics questionnaire, the Health-Promoting Lifestyle Profile II, and the systemic lupus erythematosus disease activity Index. The data were analysed through the mixed model and the logistic regression analyses.

Results:

In total, 67.5% of participants had active disease. The mean score of lifestyle was 2.49±0.30 and the lowest and the highest lifestyle dimensional mean scores were respectively related to the physical activity and the health responsibility dimensions (1.55±0.60 and 3.25±0.45). The analysis showed that each one point increase in the mean score of lifestyle was associated with 0.79 point decrease in the odds of disease activity (P = 0.006). Moreover, disease activity had significant positive relationship with body mass index (P = 0.015).

Conclusion:

Interventions for promoting lifestyle among these patients and improving healthcare providers’ knowledge about Systemic lupus erythematosus and lifestyle modification are recommended to reduce disease activity.

Validation of the minimal clinically important difference for modified activities assessment scale

BACKGROUND

The minimal clinically important difference (MCID) is the smallest change in patient-derived scores that is clinically important. We sought to validate the MCID of the modified activities assessment scale (mAAS).

METHODS

Patients were surveyed prior to undergoing abdomen/pelvis CT scans and resurveyed one year later. Before resurvey, patients were asked if they had no change, worsening, or improvement in AW-QOL. The anchor-based MCID was calculated by taking a weighted mean of the difference between control (no change) and study (worsening/improved) groups. Distribution-based approach was calculated by one-half of the standard deviation in the QOL change.

RESULTS

52.8% of 181 patients self-reported no change, 39.2% reported improvement, and 8.3% reported worsening AW-QOL. The anchor-based approach MCID was 4. The distribution-based MCID was 16.

CONCLUSION

Our study results validate prior work demonstrating similar ranges of the mAAS MCID. We recommend adopting an MCID of 5 and 15 for AW-QOL with mAAS.

Cognitive impairment in systemic lupus erythematosus is negatively related to social role participation and quality of life: A systematic review

Introduction

At least 38% of patients with Systemic Lupus Erythematosus (SLE) experience cognitive impairment (CI). Patients report CI impacts their health-related quality of life (HRQoL) and social role participation.

Objectives

To synthesize and critically appraise the quantitative literature on the relationship of CI to HRQoL and social role participation in individuals with SLE.

Methods

Six electronic databases were searched in December 2018 and June 2020 by an information specialist. Two reviewers independently completed all screening phases and data extraction; a third reviewer resolved disagreements. The Mixed Methods Appraisal Tool was used to critically appraise the quality of included studies. Data has been synthesized and analyzed descriptively to present evidence on the relationship of CI to HRQoL and social role participation.

Results

A total of 7182 references were identified and screened, with 14 articles included. Four of the included articles investigated the relationship between CI and HRQoL and all identified a negative relationship. Ten of the 14 studies investigated CI and social role participation, eight identified a negative relationship. There was heterogeneity of measures used between studies to examine CI, HRQoL, and social role participation. As such, results were interpreted descriptively and could not be pooled for meta-analysis.

Conclusion

The presence of CI is negatively related to HRQoL and social role participation in patients with SLE. Healthcare professionals should be aware of this relationship so that it can be addressed in clinical practice. Further research, using consistent methods of quantifying CI, HRQoL and social role participation, is needed to enable data pooling.

Fatigue Predicts Future Reduced Social Participation, not Reduced Physical Function or Quality of Life in People with Systemic Sclerosis

OBJECTIVE

Although fatigue is one of the most problematic symptoms for people with systemic sclerosis, little is known about how fatigue impacts daily life over time. Such information is important when developing fatigue management interventions. This study was conducted to examine 1) if fatigue severity predicted outcomes of worse functioning (social participation, physical function), and quality of life and 2) if level of self-efficacy moderated significant relationships between fatigue and these outcomes.

METHODS

Data were utilized from a clinical trial in which an online self-management intervention was tested (N = 267). Fatigue, social participation, and physical function were assessed by PROMIS measures. Quality of life was assessed by the EuroQol 5-domain instrument (EQ-5D-5L). Linear regressions were performed to examine how baseline fatigue related to functioning and quality of life outcomes 16 weeks later controlling for relevant covariates. PROMIS measures were used to measure self-efficacy in managing symptoms, daily activities, medications and treatments, emotions, and social interactions.

RESULTS

Fatigue at baseline significantly predicted social participation 16 weeks later; but did not predict physical functioning or quality of life. Self-efficacy variables did not moderate the association between fatigue and social participation.

CONCLUSION

Fatigue severity predicted decreased social participation in people with systemic sclerosis. Interventions targeting fatigue should include support to maintain participation of social roles and activities. The level of reported self-efficacy did not vary the strength of the association between fatigue and decline in social participation indicating that there may be other targets to treat fatigue intervention beyond self-management.

TRIAL REGISTRATION

NCT02494401.

Minimal Clinically Important Difference of the PROMIS Upper-Extremity Computer Adaptive Test and QuickDASH for Ligament Reconstruction Tendon Interposition Patients

PURPOSE

To calculate the minimal clinically important difference (MCID) of the Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE CAT) and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) for ligament reconstruction tendon interposition (LRTI) patients.

METHODS

Adult patients treated with LRTI for trapeziometacarpal OA by fellowship-trained hand surgeons between December 2014 and February 2018 at an academic tertiary institution were included. Outcomes were prospectively collected at each visit by tablet computer, including the QuickDASH, PROMIS UE, Pain Interference, Depression, and Anxiety CATs. Inclusion required a response to the anchor question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" on a 6-option Likert scale, as well as preoperative (≤120 days before surgery) and follow-up (2-26 weeks) outcomes. We calculated MCID both by an anchor-based approach using the mean score of the minimal change group, and with the 0.5 SD method.

RESULTS

Of 145 included participants, mean age was 63 ± 8 years and 74% were female. Anchor-based MCID estimates for the total cohort were 4.2 for the PROMIS UE CAT and 8.8 for the QuickDASH. The MCID estimates using the 0.5 SD method were 4.8 and 11.7, respectively.

CONCLUSIONS

We propose MCID values of 4.2 to 4.8 for the PROMIS UE CAT and 8.8 to 11.7 for the QuickDASH when powering clinical studies or when assessing improvement among a cohort of patients who have undergone LRTI surgery.

CLINICAL RELEVANCE

Minimal clinically important difference estimates are helpful when interpreting clinical outcomes after LRTI and for powering prospective trials.

The impact of upper limb exercise on function, daily activities and quality of life in systemic lupus erythematosus: a pilot randomised controlled trial

Objective

To assess the effect of upper limb exercise on hand function, daily activities performance and quality of life of patients with systemic lupus erythematosus (SLE).

Methods

We performed a pilot randomised, 24-week follow-up, unmasked controlled trial. Inclusion criteria were upper limb arthralgias, a Disabilities of Arm, Shoulder and Hand (DASH) questionnaire score >10 and a stable treatment over the past 3 months. Patients were randomly allocated in the routine care (control) or exercise group that received an individually tailored 30-min daily upper-limb exercise programme by a hand therapist for 12 weeks. We evaluated at 0, 6, 12 and 24 weeks the performance of daily activities for both groups with DASH questionnaire and Health Assessment Questionnaire (HAQ), the grip and pinch strength with Jamar dynamometer and pinch gauge tool, respectively, the dexterity with Purdue pegboard test, the quality of life with Lupus Quality of Life (LupusQoL) Questionnaire and the pain level by Visual Analogue Scale (VAS) score.

Results

From 293 consecutive SLE patients, data from 32 patients allocated to the exercise group and 30 to the control group were analysed. There was a significant difference between the two groups in percentage changes of DASH, HAQ, grip strength, pinch strength, LupusQoL-physical health and fatigue, and VAS scores from baseline to 6, 12 and 24 weeks, and from baseline to 12 weeks for dexterity test (p<0.001). No interaction was observed between exercise and disease activity or medication use at baseline and during the observation period.

Conclusion

Upper-limb exercise significantly improves hand function, pain, daily activity performance and quality of life in SLE.

Trial registration number

NCT03802578.

The Impact of Asthma and Chronic Obstructive Pulmonary Disease (COPD) on Patient-Reported Outcomes in Systemic Lupus Erythematosus (SLE)

Background

Risk of asthma and chronic obstructive pulmonary disease (COPD) may be elevated in systemic lupus erythematosus (SLE), but little research has studied the impact of these conditions on SLE outcomes. We examined prevalence, incidence, and impact of self‐reported asthma and COPD in two US‐based SLE cohorts (FORWARD and Lupus Outcomes Study [LOS]).

Methods

Prevalence of asthma and COPD were defined as presence of conditions at individuals’ first interviews; incidence was defined as new reports over the next 3 years. Cross‐sectional associations of asthma/COPD with patient‐reported outcomes (PROs) and longitudinal analyses associations with asthma/COPD at entry with PROs 3 years later were examined.

Results

In FORWARD, 19.8% and 8.3% participants reported asthma and COPD, respectively, at entry. In LOS, 36.0% reported the presence of either (US population comparisons: asthma, 9.7%; COPD, 6.1%). Cross‐sectionally, asthma/COPD was associated with worse PROs, including disease activity. In FORWARD, individuals with asthma experienced greater worsening of fatigue, pain, and global health ratings longitudinally; individuals with COPD experienced greater increases in self‐reported SLE activity. However, no such patterns were noted in the LOS.

Conclusion

Asthma and COPD appeared to be more common in SLE than in the general US population and were associated with worse status on PROs cross‐sectionally. Asthma was linked to decrements in PROs longitudinally.

Minimal clinically important difference for asthma endpoints: an expert consensus report

Minimal clinically important difference (MCID) can be defined as the smallest change or difference in an outcome measure that is perceived as beneficial and would lead to a change in the patient's medical management.

The aim of the current expert consensus report is to provide a “state-of-the-art” review of the currently available literature evidence about MCID for end-points to monitor asthma control, in order to facilitate optimal disease management and identify unmet needs in the field to guide future research.

A series of MCID cut-offs are currently available in literature and validated among populations of asthmatic patients, with most of the evidence focusing on outcomes as patient reported outcomes, lung function and exercise tolerance. On the contrary, only scant and partial data are available for inflammatory biomarkers. These clearly represent the most interesting target for future development in diagnosis and clinical management of asthma, particularly in view of the several biologic drugs in the pipeline, for which regulatory agencies will soon require personalised proof of efficacy and treatment response predictors.

Minimal clinically important difference (MCID) cut-offs in asthma are validated for patient reported outcomes and lung function, but not for inflammatory biomarkers. MCID represents a key target for future development in asthma management. http://bit.ly/33hcWIe

Minimal Clinically Important Difference After Carpal Tunnel Release Using the PROMIS Platform

PURPOSE

In light of recently-proposed quality measures for carpal tunnel release (CTR), elucidating the minimal clinically important difference (MCID) for selected outcome measures will be important when interpreting treatment responses. Our purpose was to estimate the MCID of the Patient-Reported Outcomes Measurement Information System (PROMIS) instruments and the short Disabilities of the Arm, Shoulder, and Hand (QuickDASH) following CTR.

METHODS

Adult patients undergoing isolated unilateral CTR between July 2014 and October 2016 were identified. Outcomes included the PROMIS Upper Extremity (UE) Computer Adaptive Test (CAT), Physical Function (PF) CAT, QuickDASH, and Pain Interference (PI) CAT. For inclusion, pretreatment baseline (within 60 days of surgery) and postoperative (6-90 days) UE or PF CAT scores were required, as well as a response on a 5-point Likert scale to the question "How much relief and/or improvement do you feel you have experienced as a result of your treatment?" The MCID was calculated using SD and minimum detectable change (MDC) distribution methods.

RESULTS

In response to the Likert scale question, 88.6% of patients reported improvement at a mean of 14.8 days after surgery. The infrequency of patients reporting no change (5 of 44; 11.4%) precluded calculation of a statistically sound anchor-based MCID value. The MCID values, as calculated using the one-half SD method, were 3.6, 4.6, 10.4, and 3.4 for the UE CAT, PF CAT, QuickDASH, and PI CAT, respectively.

CONCLUSIONS

We have calculated MCID values for the UE CAT, PF CAT, QuickDASH, and PI CAT for patients undergoing CTR. Although the small number of patients reporting no change and minimal change after surgery precluded an anchor-based MCID calculation, we report estimates using the one-half SD method for the MCID following CTR.

CLINICAL RELEVANCE

These MCID estimates will be helpful when interpreting CTR clinical outcomes and for powering prospective trials.

The minimal clinically important difference of the dyspnea index in laryngotracheal stenosis

OBJECTIVE

The Dyspnea Index (DI) is a validated patient-reported outcome (PRO) instrument that has been used in the management of laryngotracheal stenosis (LTS). The minimal clinically important difference (MCID) is an established concept to help determine the change in a PRO instrument that reflects meaningful change for the patient. It is not known what change in the DI is of clinical significance in airway surgery. This study aims to determine the MCID for the DI in patients undergoing surgical treatment for LTS.

METHODS

This is a prospective cohort study in which 26 patients with LTS completed the DI (score range 0 to 40) before and 6 to 8 weeks postoperatively, in addition to a Global Ratings Change Questionnaire (GRCQ), scored from -7 to +7, at the postoperative interval. A hypothesis test was carried out to test the association between GRCQ and change in DI. The MCID for change in DI was determined using anchor-based analysis.

RESULTS

Overall mean change in DI was -11, and mean change in GRCQ was +5. Change in DI scores were significantly different among the improvement and no improvement groups (P value <0.002). Area under the receiver operating curve was 0.92, demonstrating high discriminatory ability of the change in DI score. A change of -4 was determined to be the threshold that discriminated between significant improvement and no improvement.

CONCLUSION

A decrease of 4 in the DI can be considered as the MCID for patients with LTS after surgical treatment.

LEVEL OF EVIDENCE

2b Laryngoscope, 130:1775-1779, 2020.

The Impact of Frailty on Changes in Physical Function and Disease Activity Among Adults With Rheumatoid Arthritis

Objective

Reduced physical function and frailty are common in rheumatoid arthritis (RA). However, relationships between frailty and changes in physical function and disease activity over time in RA are unknown. We tested whether frailty is a risk factor for worsening patient-reported physical function and disease activity in RA.

Methods

Adults from a longitudinal RA cohort (N = 124) participated. By using an established frailty definition, individuals with three or more of the following deficits were considered frail: 1) body mass index less than or equal to 18.5, 2) low grip strength, 3) severe fatigue, 4) slow 4-m walking speed, and 5) low physical activity. Individuals with one to two or zero deficits were considered "pre-frail" or "robust," respectively. Physical function and RA disease activity were assessed by the Health Assessment Questionnaire (HAQ) and Rheumatoid Arthritis Disease Activity Index (RADAI), respectively, at baseline and follow-up 2 years later. Regression analyses modeled associations of frailty status with change in HAQ and RADAI scores between baseline and follow-up with and without controlling for covariates. Associations of individual frailty components with change in HAQ and RADAI scores were also examined.

Results

Among adults with RA, baseline frailty status predicted significant increases, or worsening, in HAQ (β: 0.4; 95% confidence interval: 0.1-0.8; P < 0.01) but not RADAI scores (β: 0.5; 95% confidence interval: -0.4 to 1.5; P > 0.05) between baseline and follow-up in fully adjusted models. Fatigue was an important contributor to this effect.

Conclusion

Frailty may be an important risk factor for reduced physical function over time in RA. Future studies should address whether interventions to reduce frailty improve physical function in RA.

Effectiveness of Occupational Therapy Interventions for Adults With Systemic Lupus Erythematosus: A Systematic Review

OBJECTIVE. Our objective was to assess the efficacy of occupational therapy–related interventions for adults with systemic lupus erythematosus (SLE).

METHOD. We reviewed intervention studies published from 2000 to 2017. The method used for conducting the review was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The PEDro scale was used to evaluate methodological quality. Risk of bias was appraised with methods described by the Cochrane Methods Group.

RESULTS. The final analysis included 20 studies (10 physical activity and 10 psychoeducational). Moderate evidence supports physical activity to improve depression, fatigue, exercise tolerance, and function without exacerbation of disease symptoms. Strong evidence supports psychoeducational interventions using cognitive–behavioral approaches to improve pain, depression, anxiety, perceived stress, quality of life, and function. Moderate evidence supports patient education and self-management interventions for pain, depression, anxiety, perceived stress, quality of life, and function.

CONCLUSION. Further research on occupation-based interventions for people with SLE is needed.

BRIGHT Coaching: A Randomized Controlled Trial on the Effectiveness of a Developmental Coach System to Empower Families of Children With Emerging Developmental Delay

Background: In preschool-aged children with, or at elevated risk for, developmental disabilities, challenges and needs arise from vulnerabilities linked to critical and newly emerging cognitive, speech, motor, behavioral, and social skills. For families, this can be a stressful period as they witness the gradual unfolding of their child's differences and await to receive care. Nationally and internationally, service delivery models during this critical period are not standardized nor are they nimble or sufficient enough, leading to long wait times, service gaps and duplications. Given these struggles, there is a need to examine whether "health coaching", a structured educational program that is deliverable by different and more accessible means, can be effective in empowering families, by delivering information, providing social supports, and decreasing the demands on the overwhelmed health and developmental services. The primary objective is to evaluate the feasibility and the effectiveness of a coaching intervention (in comparison to usual and locally available care), for parents of children with emerging developmental delays. Method/Design: A multi-centered pragmatic randomized controlled trial design will be used. Families will be recruited from a representative sample of those awaiting publicly-funded regional child health services for children with developmental delays in four Canadian provinces. The target sample size is 392 families with children aged 1.5 to 4.5 years at recruitment date. Families will be randomly assigned to receive either the BRIGHT Coaching intervention (coach supported, hardcopy and online self-managed educational resources: 14 sessions, 2 sessions every 4 weeks for 6-9 months) or usual care that is locally available. In addition to the feasibility and acceptability measures, outcomes related to family empowerment, parental satisfaction and efficacy with caregiver competency will be evaluated at baseline, post-treatment (8 months), and follow-up (12 months). Discussion: This manuscript presents the background information, design, description of the interventions and of the protocol for the randomized controlled trial on the effectiveness of BRIGHT Coaching intervention for families of children with emerging developmental delays. Trial Registration: ClinicalTrials.gov, U.S. National Library of Medicine, National Institutes of Health #NCT03880383, 03/15/2019. Retrospectively registered.

Productivity Losses and Costs in the Less-Common Systemic Autoimmune Rheumatic Diseases

PURPOSE OF REVIEW

We synthesised the literature on productivity losses and costs in the less-common systemic autoimmune rheumatic diseases: Sjogren's syndrome (SjS), systemic sclerosis (SSc), poly/dermatomyositis (PM/DM), and systemic vasculitides (SV).

RECENT FINDINGS

Of 29 studies located, 12 were published 2012 onwards (SSc = 6, SjS = 2, PM/DM = 2, SV = 2). In these, 25% of PM/DM, and 21-26% of SV, were work disabled, 22% of SSc stopped work within 3 years of diagnosis, and annual costs of absenteeism in SSc averaged $12,024 2017 USD. Very few studies reported on costs, presenteeism (working at reduced levels), or unpaid productivity loss. Across multiple systemic autoimmune rheumatic diseases (SARDs), major drivers of lost productivity were generalised items like pain, depression, and fatigue, rather than disease-specific factors. Evidence suggests that work disability is common in SSc and strikes quickly. However, in SSc and other SARDs, more comprehensive estimates are needed, which include absenteeism and presenteeism from paid and unpaid work, costs, and drivers of productivity loss.

Filling the gaps in SARDs research: collection and linkage of administrative health data and self-reported survey data for a general population-based cohort of individuals with and without diagnoses of systemic autoimmune rheumatic disease (SARDs) from British Columbia, Canada

PURPOSE

Systemic autoimmune rheumatic diseases (SARDs) are a group of debilitating autoimmune diseases, including systemic lupus erythematosus and related disorders. Assessing the healthcare and economic burden of SARDs has been challenging: while administrative databases can be used to determine healthcare utilisation and costs with minimal selection and recall bias, other health, sociodemographic and economic data have typically been sourced from highly selected, clinic-based cohorts. To address these gaps, we are collecting self-reported survey data from a general population-based cohort of individuals with and without SARDs and linking it to their longitudinal administrative health data.

PARTICIPANTS

Using administrative data from the province of British Columbia (BC), Canada, we established a population-based cohort of all BC adults receiving care for SARDs during 1996-2010 (n=20 729) and non-SARD individuals randomly selected from the general population. BC Ministry of Health granted us contact information for 12 000 SARD and non-SARD individuals, who were recruited to complete the surveys by mail or online.

FINDINGS TO DATE

Four hundred individuals were initially invited to participate, with 135 (34%) consenting and 127 (94%) submitting the first survey (72% completed online). Sixty-three (49.6%) reported ≥1 SARD diagnosis. The non-SARDs group (n=64) was 92% female with mean age 57.0±11.6 years. The SARDs group (n=63) was 94% female with mean age 56.5±13.1 years. Forty-eight per cent of those with SARDs were current-or-former smokers (mean 10.6±16.2 pack-years), and 33% were overweight or obese (mean body mass index of 24.4±5.3).

FUTURE PLANS

Health and productivity data collected from the surveys will be linked to participants' administrative health data from the years 1990-2013, allowing us to determine the healthcare and lost productivity costs of SARDs, and assess the impact of patient-reported variables on utilisation, costs, disability and clinical outcomes. Findings will be disseminated through scientific conferences and peer-reviewed journals.

Impact of disease activity on health-related quality of life in systemic lupus erythematosus - a cross-sectional analysis of the Swiss Systemic Lupus Erythematosus Cohort Study (SSCS)

Background

To assess the impact of disease activity on health-related quality of life (HRQoL) in systemic lupus erythematosus (SLE).

Methods

Cross-sectional study of patients included in the Swiss SLE Cohort Study between April 2007 and June 2014. HRQoL outcomes were based on the Medical Outcome Study Short Form 36 (SF-36). Disease activity was assessed by the SLE Disease Activity Index score with the Safety of Estrogens in SLE National Assessment modification (SELENA-SLEDAI) and by the physican’s global assessment (PGA).

Results

Of the 252 patients included, 207 (82%) were women. Median [interquartile range (IQR)] age was 43 [32–57] years. SLE was active in 125 patients (49.6%). Median [IQR] mental component summary (MCS) in active vs inactive SLE was 40.0 [30.2–51.0] compared to 47.3 [39.2–52.8] (p < 0.01) and median [IQR] physical component summary (PCS) 43.7 [37.0–52.8] compared to 49.1 [38.4–55.6], respectively (p < 0.05). Increase in SELENA-SLEDAI or increase in PGA were negatively correlated with PCS and/or MCS. After adjusting for gender, age and disease duration, disease activity impacted on both PCS and MCS and all subscales except general health. Active lupus nephritis and musculoskeletal involvement were associated with physical limitations and emotional problems, increased bodily pain and poor social functioning. Low complement and/or presence of anti-dsDNA antibodies were associated with increased fatigue and reduced mental health.

Conclusions

In patients with SLE, HRQoL is reduced in those with active disease. Impact of disease activity on HRQoL dimensions depends on SELENA-SLEDAI system components.

Electronic supplementary material

The online version of this article (doi:10.1186/s12865-017-0200-5) contains supplementary material, which is available to authorized users.

Is frailty a relevant concept in SLE?

Objective

In geriatric populations, frailty is associated with poor health outcomes, including mortality. Frailty has not been examined in lupus, although components of the phenotype seem relevant.

Methods

Women with lupus (n=152) participated in research visits in 2008–2009. Frailty was assessed by Fried's frailty phenotype criteria: low weight/unintentional weight loss, slow gait (4-m walk using sex and height criteria), weakness (grip strength using gender and body mass index criteria), exhaustion (2 specific questions) and inactivity (from physical activity questionnaire). Women accumulating 3+ components were classified as ‘frail’, one or two components as ‘prefrail’, and none as ‘robust’. Physical function (36-item Short Form (SF-36) Physical Functioning subscale and Valued Life Activities disability scale), cognitive function (from a 12-test battery) and mortality were examined as outcomes. Mortality was determined as of December 2015. Multiple regression analyses examined concurrent and 2-year function controlling for age, lupus duration, race/ethnicity, glucocorticoid use, obesity, self-reported disease activity and damage and, for longitudinal analyses, baseline function. Mortality analyses controlled for age, lupus duration and baseline disease damage scores.

Results

Mean age was 48 (±12) years, mean lupus duration was 16 (±9) years. 20% of the sample was classified as frail and 50% as prefrail. Frail women had significantly worse physical functioning than both robust and prefrail women and were more likely to have cognitive impairment. Frail women were also more likely to experience declines in functioning and onset of cognitive impairment. Mortality rates were significantly higher in the frail group (frail 19.4%; prefrail 3.9%; robust 2.3%). Odds (95% CI) of death for frail women were elevated, even after adjusting for age, lupus duration and baseline disease damage (5.9 (0.6 to 57.1)).

Conclusions

Prevalence of frailty in this sample of women with lupus was higher than in samples of older adults. Frailty was associated with poor physical and cognitive function, functional declines and mortality.

Frailty and reduced physical function go hand in hand in adults with rheumatoid arthritis: a US observational cohort study

Reduced physical function and health-related quality of life are common in rheumatoid arthritis (RA), and further studies are needed that examine novel determinates of reduced physical function in RA. This study examines whether frailty, a state of increased vulnerability to stressors, is associated with differences in self-reported physical function among adults with RA. Adults from a longitudinal RA cohort (n = 124) participated in the study. Using an established definition of frailty, individuals with three or more of the following physical deficits were classified as frail: (1) body mass index ≤18.5, (2) low grip strength (adjusted for sex and body mass index (BMI), measured by handheld dynamometer), (3) severe fatigue (measured by the Multidimensional Assessment of Fatigue), (4) slow 4-m walking speed (adjusted for sex and height), and (5) low physical activity (measured by the International Physical Activity Questionnaire). Individuals with one or two deficits were classified as "pre-frail" and those with no deficits as "robust." Self-reported physical function was assessed by the Health Assessment Questionnaire (HAQ) and the Valued Life Activities Difficulty scale. Regression analyses modeled associations of frailty category with HAQ and Valued Life Activities (VLA) Difficulty scores with and without controlling for age, sex, disease duration, C-reactive protein, use of oral steroids, and pain. Among adults with RA, being frail compared to being robust was associated with a 0.44 worse VLA score (p < 0.01) when the effects of covariates are held constant. Being frail, compared to being robust, is associated with clinically meaningful differences in self-reported physical function among adults with RA.

The systemic lupus erythematosus travel burden survey: baseline data among a South Carolina cohort

BACKGROUND

Many studies on the impact of systemic lupus erythematosus or lupus have identified patient travel costs as being problematic. We administered a survey that examined the impact of self-rated travel burden on lupus patients. The systemic lupus erythematosus travel burden survey included 41 patients enrolled in the systemic lupus erythematosus database project at the Medical University of South Carolina.

RESULTS

Most participants reported that travel caused medications to be discontinued or appointments to be missed. In unadjusted logistic regressions of the relationship between these outcomes and medical travel burden, both distance to rheumatologists and time to lupus medical care were significant.

CONCLUSIONS

Our findings suggest that more research is needed to examine the influence of travel burden among this population, but data from this report could help to inform physicians, academic researchers, and other health professionals in South Carolina and other areas with significant rural populations on how travel burden may impact patients receiving care for lupus and provide an opportunity for the development of interventions aimed at assisting lupus patients with management of stressors related to travel burden.

Muscle Strength and Changes in Physical Function in Women With Systemic Lupus Erythematosus

OBJECTIVE

Cross-sectional studies have observed that muscle weakness is associated with worse physical function among women with systemic lupus erythematosus (SLE). The present study examines whether reduced upper and lower extremity muscle strength predict declines in function over time among adult women with SLE.

METHODS

One hundred forty-six women from a longitudinal SLE cohort participated in the study. All measures were collected during in-person research visits approximately 2 years apart. Upper extremity muscle strength was assessed by grip strength. Lower extremity muscle strength was assessed by peak knee torque of extension and flexion. Physical function was assessed using the Short Physical Performance Battery (SPPB). Regression analyses modeled associations of baseline upper and lower extremity muscle strength with followup SPPB scores controlling for baseline SPPB, age, SLE duration, SLE disease activity (Systemic Lupus Activity Questionnaire), physical activity level, prednisone use, body composition, and depression. Secondary analyses tested whether associations of baseline muscle strength with followup in SPPB scores differed between intervals of varying baseline muscle strength.

RESULTS

Lower extremity muscle strength strongly predicted changes over 2 years in physical function even when controlling for covariates. The association of reduced lower extremity muscle strength with reduced physical function in the future was greatest among the weakest women.

CONCLUSION

Reduced lower extremity muscle strength predicted clinically significant declines in physical function, especially among the weakest women. Future studies should test whether therapies that promote preservation of lower extremity muscle strength may prevent declines in function among women with SLE.

Quality of life and acquired organ damage are intimately related to activity limitations in patients with systemic lupus erythematosus

Background

Systemic lupus erythematosus (SLE) is an autoimmune multi-organ disease, characterized by episodes of disease flares and remissions over time, which may restrain affected patients’ ability to perform daily activities. The purpose of the present study was to characterize variation in activity limitations among well-defined SLE patients, and to describe disease phenotypes, acquired organ damage and their relations to activity limitation and self-reported health, respectively.

Methods

The disease phenotypes were organized into 4 different clinical groups and logistic regression analyses were used to identify how an elevated health assessment questionnaire (HAQ) score was related to disease variables such as phenotypes, disease activity and damage accrual. Correlation and multiple linear regression analyses were used to examine the association between each group of variables – background variables, disease variables and self-reported measurements – and the degree of elevated HAQ.

Results

We found a higher proportion of activity limitation in patients with skin and joint involvement compared to others. The presence of activity limitation, as detected by the HAQ instrument, was significantly associated with quality of life (EuroQol–5D) and accrual of organ damage using the Systemic Lupus International Collaborative Clinics/ACR damage index.

Conclusions

The findings highlight the differing requirements of the multi-professional rehabilitation interventions for the various SLE phenotypes in order to optimize the clinical care of the patients.

Systemic lupus erythematosus observations of travel burden: A qualitative inquiry

AIMS

Explorations of travel impediments among patients suffering from rheumatic diseases have been very limited. Research has consistently indicated a shortage of rheumatologists, resulting in patients potentially having to travel long distances for care. The purpose of our study was to explore how systemic lupus erythematosus (SLE) patients experience travel issues differentially by race and socio-economic status.

METHODS

We conducted semi-structured interviews and a brief demographic survey with 10 patients diagnosed with SLE. Interview transcripts were coded and analyzed using NVivo Analysis Software to facilitate the reporting of recurrent themes and supporting quotations, and an initial codebook was independently developed by two researchers on the study team and then verified together.

RESULTS

Patients described three major areas of concern with respect to travel burden in accessing their rheumatologists: reliance on caregivers; meeting financial priorities; and pain and physical limitations.

CONCLUSIONS

Our data suggest general traveling challenges interfering with medical appointment compliance for several participants and the importance of socio-economic issues when considering travel issues. This study highlights an important area with implications for adherence to medical appointments and participation in research among patients with SLE.

Approaches for estimating minimal clinically important differences in systemic lupus erythematosus

A minimal clinically important difference (MCID) is an important concept used to determine whether a medical intervention improves perceived outcomes in patients. Prior to the introduction of the concept in 1989, studies focused primarily on statistical significance. As most recent clinical trials in systemic lupus erythematosus (SLE) have failed to show significant effects, determining a clinically relevant threshold for outcome scores (that is, the MCID) of existing instruments may be critical for conducting and interpreting meaningful clinical trials as well as for facilitating the establishment of treatment recommendations for patients. To that effect, methods to determine the MCID can be divided into two well-defined categories: distribution-based and anchor-based approaches. Distribution-based approaches are based on statistical characteristics of the obtained samples. There are various methods within the distribution-based approach, including the standard error of measurement, the standard deviation, the effect size, the minimal detectable change, the reliable change index, and the standardized response mean. Anchor-based approaches compare the change in a patient-reported outcome to a second, external measure of change (that is, one that is more clearly understood, such as a global assessment), which serves as the anchor. Finally, the Delphi technique can be applied as an adjunct to defining a clinically important difference. Despite an abundance of methods reported in the literature, little work in MCID estimation has been done in the context of SLE. As the MCID can help determine the effect of a given therapy on a patient and add meaning to statistical inferences made in clinical research, we believe there ought to be renewed focus on this area. Here, we provide an update on the use of MCIDs in clinical research, review some of the work done in this area in SLE, and propose an agenda for future research.

Muscle strength, muscle mass, and physical disability in women with systemic lupus erythematosus

OBJECTIVE

Data describing relationships between muscle strength, muscle mass, and physical disability among individuals with systemic lupus erythematosus (SLE) are limited. The present study examines the relationship of muscle strength and muscle mass with physical disability among adult women with SLE.

METHODS

A total of 146 women from a longitudinal SLE cohort participated in the study. All measures were collected during an in-person research visit. Lower extremity muscle strength was assessed by peak knee torque of extension and flexion and by chair-stand time. Total lean body mass, appendicular lean mass, and fat mass (kg/m(2) ) were measured by whole-body dual x-ray absorptiometry. Self-reported physical disability was assessed using the Short Form 36 health survey (SF-36) physical functioning subscale, and the Valued Life Activities (VLA) disability scale. Spearman's rank correlation coefficients tested the correlations between muscle strength, muscle mass, and disability scores. Regression analyses modeled the effect of lower extremity muscle strength and mass on SF-36 and VLA disability scores controlling for age, SLE duration, SLE disease activity measured with the Systemic Lupus Activity Questionnaire, physical activity level, prednisone use, body composition, and depression.

RESULTS

On all measures, reduced lower extremity muscle strength was associated with poorer SF-36 and VLA disability scores. Trends persisted after adjustment for covariates. Muscle mass was moderately correlated with muscle strength, but did not contribute significantly to adjusted regression models.

CONCLUSION

Lower extremity muscle strength, but not muscle mass, was strongly associated with physical disability scores. While further studies are needed, these findings suggest that improving muscle strength may reduce physical disability among women with SLE.

Health technology assessment of belimumab: a new monoclonal antibody for the treatment of systemic lupus erythematosus

Objective. Systemic lupus erythematosus (SLE) is treated with anti-inflammatory and immunosuppressive drugs and off-label biologics. Belimumab is the first biologic approved after 50 years as an add-on therapy for active disease. This paper summarizes a health technology assessment performed in Italy. Methods. SLE epidemiology and burden were assessed using the best published international and national evidences and efficacy and safety of belimumab were synthesized using clinical data. A cost-effectiveness analysis was performed by a lifetime microsimulation model comparing belimumab to standard of care (SoC). Organizational and ethical implications were discussed. Results. Literature review showed that SLE affects 47 per 100,000 people for a total of 28,500 patients in Italy, 50% of whom are affected by active form of the disease despite SoC. These patients, if autoantibodies and anti-dsDNA positive with low complement, are eligible for belimumab. SLE determines work disability and a 2–5-fold increase in mortality. Belimumab with SoC may prevent 4,742 flares in three years being cost-effective with an incremental cost-effectiveness ratio of €32,859 per quality adjusted life year gained. From the organizational perspective, the development of clear and comprehensive clinical pathways is crucial. Conclusions. The assessment supports the use of belimumab into the SLE treatment paradigm in Italy.

Effects of psychological interventions for patients with systemic lupus erythematosus: a systematic review and meta-analysis

The purpose of this systematic review was to quantify the effects of psychological interventions on psychological health, physical health and disease activity in patients with systemic lupus erythematosus (SLE). Studies were identified through a systematic search of six electronic databases and were included if they used a randomized controlled trial designed to explore the effects of psychological interventions in patients with SLE. Two authors independently assessed the methodological quality of included studies using a quality-scoring instrument developed by Jadad et al. and extracted relevant information according to a pre-designed extraction form. Data was analysed using the Cochrane Collaboration’s Revman5.1. Finally, six studies involving 537 patients were included. Meta-analysis showed that psychological interventions could reduce the levels of anxiety (standard mean difference (SMD) −0.95, 95% confidence interval (CI) −1.57,−0.34, p-value 0.00), depression (SMD −1.14, 95% CI −1.84,−0.44, p-value 0.00), stress (SMD −0.63, 95% CI −1.02,−0.23, p-value 0.00), and disease activity (SMD −0.34, 95% CI −0.57,−0.11, p-value 0.00). Although the effects on mental health, fatigue and physical function were in the expected direction, they were not statistically significant ( p > 0.05). The present data indicate that psychological interventions are promising treatments for patients with SLE. The findings were based on only six randomized controlled trials (RCTs), some of which were relatively small, so more methodologically rigorous large-scale randomized controlled trials are required to confirm these preliminary estimates of effectiveness.

[Systemic lupus erythematosus in the elderly]

Late-onset systemic lupus erythematosus (SLE) usually appears in patients older than 65 years and has clinical features different from the classical form observed in younger patients. In the elderly, SLE represents 10-20% of all SLE cases, shows a different and less aggressive clinical evolution and the first manifestations are non-specific. A significantly higher incidence of late-onset SLE in males, and the fact that postmenopausal women have a more benign disease, suggests that the estrogenic status may influence the activity of the disease. Owing to the insidious onset and the non-specific clinical manifestations on presentation, there is commonly a delayed diagnosis of late-onset SLE. Furthermore, the presence of comorbidities and concomitant therapies in elderly patients may limit the therapeutic options for SLE. The treatment of choice of joint symptoms and serositis includes non-steroidal anti-inflammatory drugs and low-dose steroids for short periods. In addition to the need for adopting a multidisciplinary approach, it is fundamental to obtain information about the functional, cognitive and social status of these patients in order to make appropriate healthcare decisions.

Development and validation of a short form of the valued life activities disability questionnaire for rheumatoid arthritis

OBJECTIVE

To develop and validate a shortened version of the Valued Life Activities disability and accommodations scale (VLA) for individuals with rheumatoid arthritis (RA).

METHODS

To shorten the existing VLA measure, item response theory analyses were conducted using data from 449 patients with RA. Next, the resulting 14-item shortened version of the VLA scale (S-VLA) was evaluated by structured interviews among 20 RA patients. Lastly, the S-VLA was administered to 150 RA patients along with other measures, including the Health Assessment Questionnaire (HAQ) and Short Form 36 (SF-36). A random sample of 50 patients completed the S-VLA 2 weeks later to assess reliability. Item statistics were calculated to evaluate correlations between individual items and the S-VLA total score. Correlations between the S-VLA and other measures were used to evaluate validity.

RESULTS

Test-retest reliability was 0.91, while Cronbach's alpha for the S-VLA was 0.95. None of the 14 items was associated with improved alpha coefficients when omitted. All of the items were strongly correlated with the S-VLA total score. S-VLA scores were highly positively correlated with the HAQ (r = 0.81, P ≤ 0.001), patient-reported disease activity (r = 0.71, P ≤ 0.001), satisfaction with abilities (r = 0.82, P ≤ 0.001), and number of days with activity limitations (r = 0.65, P ≤ 0.001). In addition, as hypothesized, the S-VLA was inversely correlated with the SF-36 physical component summary score (r = -0.78, P ≤ 0.001) and the physical functioning (r = -0.80, P ≤ 0.001), role physical (r = -0.67, P ≤ 0.001), and social functioning (r = -0.72, P ≤ 0.001) subscales.

CONCLUSION

The S-VLA is a short, valid, and reliable instrument that may prove useful for monitoring disability among individuals with RA.

Parenting: the forgotten role of women living with systemic lupus erythematosus

This study investigates parenting and the impact of symptoms, such as pain and fatigue, on the parenting abilities of mothers with systemic lupus erythematosus (SLE). Participants were 68 mothers with SLE who had children 18 years of age and younger. The mothers completed surveys consisting of a demographic questionnaire and self-report instruments such as the Parenting Disability Index (PDI), Health Assessment Questionnaire, Pain Visual Analog Scale, and Multidimensional Assessment of Fatigue Scale. Analysis of variance was used to compare parenting abilities for women with younger children (birth -5 years) and women with older children (6-18 years) and women with children in both age groups. There were no significant differences between the three groups. However, having more fatigue, functional disability, and less education resulted in higher PDI scores in all groups. Mothers with children younger than age 5 reported that having energy to talk/listen to a child was the most difficult parenting task. Mothers with children between 6 and 18 years of age reported the most difficulties with maintaining discipline, playing games, shopping, and doing household chores. Symptoms of lupus have a significant influence on mothering roles. In daily practice, health care providers may want to consider inquiring about the impact SLE may be having on their patients' parenting roles.

Development and assessment of the constipation-related disability scale

BACKGROUND

Chronic constipation is associated with impaired quality of life and physical discomfort. Although inability to engage in day-to-day activities has been significantly associated with psychological distress, limited research has examined this relationship in constipated samples.

AIM

To develop and validate the Constipation-Related Disability Scale (CRDS), which assesses the extent of disability caused by constipation.

METHODS

A total of 240 constipated participants and 103 healthy controls completed the CRDS. Reliability was measured with Cronbach's coefficient alpha and test-retest reliability was assessed with intraclass correlation coefficients. Convergent, divergent and predictive validity were assessed.

RESULTS

Component and factor analyses were used to derive two factors: Work/Leisure Activities and Activities of Daily Living, as well as a total CRDS score. Good reliability was found, with alphas ≥ 0.87 and intraclass correlation coefficients ≥ 0.85. All scales were negatively correlated with the physical health subscales of the SF-36 (P < 0.001) and were not significantly correlated with the Epworth Sleepiness Scale and Social Desirability Scale, providing support for convergent and divergent validity, respectively. Evidence of predictive validity was supported by associations between the total CRDS with number of physician visits per year (P < 0.01), missed work in the last year (odds ratio [OR = 1.11, 95% confidence interval [CI] = 1.06-1.19, P < 0.001) and ER visits in the last year (OR = 1.08, 95% CI = 1.00-1.16, P < 0.05).

CONCLUSIONS

The Constipation-Related Disability Scale is the first instrument that assesses the impact of constipation on daily activities. There is evidence of strong reliability and validity of the instrument.

Impact of obesity on functioning among women with systemic lupus erythematosus

OBJECTIVE

Obesity is associated with high rates of disability in the general population. The nature of the relationship between obesity and disability in systemic lupus erythematosus (SLE), a condition with a high background rate of disability, is unknown.

METHODS

Data were from 2 interviews, 4 years apart, of a longitudinal cohort of individuals with SLE (n = 716 women). Body mass index (BMI) was calculated from self-reported height and weight; obesity was classified by usual (BMI ≥30) and revised (BMI ≥26.8) definitions. Three measures of functioning were examined: the Short Form 36 (SF-36) Health Survey physical function (PF) subscale, Valued Life Activities (VLA) Disability Questionnaire, and employment. Multivariate analyses controlled for demographics, SLE duration and disease activity, glucocorticoid use, depression, and comorbidities. Prospective analyses also controlled for baseline function.

RESULTS

At a BMI of ≥30, 27.8% of the subjects were obese; at a BMI of ≥26.8, 40.6% of the subjects were obese. Regardless of obesity definition, obese women exhibited poorer baseline function, with decrements ranging from 20-33% depending on the functional measure and obesity definition. With a BMI of ≥26.8, the adjusted SF-36 PF scores were 4.3 points lower for obese women (P < 0.0001), VLA difficulty was 0.09 higher (P = 0.01), and odds of employment were 80% of nonobese women (odds ratio 0.8, 95% confidence interval 0.5-1.1). At the 4-year followup, women who were obese at baseline had poorer function and experienced greater functional declines.

CONCLUSION

Obesity was associated with clinically significant negative effects on function, both concurrently and prospectively. This negative impact occurred at a lower BMI than is often considered problematic clinically. Because of the high rate of SLE-related disability, addressing preventable risk factors such as obesity may improve long-term SLE outcomes.

Disability in valued life activities among individuals with COPD and other respiratory conditions

PURPOSE

The purpose of this study was to delineate the effect of chronic obstructive pulmonary disease (COPD) on a broad range of valued life activities (VLAs) and make comparisons to effects of other airways conditions.

METHODS

We used cross-sectional data from a population-based, longitudinal study of US adults with airways disease. Data were collected by telephone interview. VLA disability was compared among 3 groups defined by reported physician diagnoses: COPD/emphysema, chronic bronchitis, and asthma. Multiple regression analyses were conducted to identify independent predictors of VLA disability.

RESULTS

About half of individuals with COPD were unable to perform at least 1 VLA; almost all reported at least 1 VLA affected. The impact among individuals with chronic bronchitis and asthma was less but still notable: 74%-84% reported at least 1 activity affected, and about 15% were unable to perform at least 1 activity. In general, obligatory activities were the least affected. Symptom measures and functional limitations were the strongest predictors of disability, independent of respiratory condition.

CONCLUSION

VLA disability is common among individuals with COPD. Obligatory activities are less affected than committed and discretionary activities. A focus on obligatory activities, as is common in disability studies, would miss a great deal of the impact of these conditions. Because individuals are often referred to pulmonary rehabilitation as a result of dissatisfaction with ability to perform daily activities, VLA disability may be an especially relevant outcome for rehabilitation.