Racial/Ethnic variation in all-cause mortality among United States medicaid recipients with systemic lupus erythematosus: a Hispanic and asian paradox

Lupus and other autoimmune diseases: Epidemiology in the population of African ancestry and diagnostic and management challenges in Africa

Autoimmune diseases are prevalent among people of African ancestry living outside Africa. However, the burden of autoimmune diseases in Africa is not well understood. This article provides a global overview of the current burden of autoimmune diseases in individuals of African descent. It also discusses the major factors contributing to autoimmune diseases in this population group, as well as the challenges involved in diagnosing and managing autoimmune diseases in Africa.

Multiplicative Impact of Adverse Social Determinants of Health on Outcomes in Lupus Nephritis: A Meta-analysis and Systematic Review

OBJECTIVE

Social determinants of health (SDoH) likely contribute to outcome disparities in lupus nephritis (LN). Understanding the overall burden and contribution of each domain could guide future health equity-focused interventions to improve outcomes and reduce disparities in LN. Objectives of this meta-analysis were to 1) determine the association of overall SDoH and specific SDoH domains on LN outcomes and 2) develop a framework for the multidimensional impact of SDoH on LN outcomes.

METHODS

We performed a comprehensive search of studies measuring associations between SDoH and LN outcomes. We examined pooled odds of poor LN outcomes including death, end-stage kidney disease, or cardiovascular disease in patients with and without adverse SDoH. Additionally, we calculated the pooled odds ratios of outcomes by four SDoH domains: individual (eg, insurance), health care (eg, fragmented care), community (eg, neighborhood socioeconomic status), and health behaviors (eg, smoking).

RESULTS

Among 531 screened studies, 31 meeting inclusion criteria and 13 with raw data were included in meta-analysis. Pooled odds of poor outcomes were 1.47-fold higher in patients with any adverse SDoH. Patients with adverse SDoH in individual and health care domains had 1.64-fold and 1.77-fold higher odds of poor outcomes. We found a multiplicative impact of having two or more adverse SDoH on LN outcomes. Black patients with public insurance and fragmented care had 12-fold higher odds of poor LN outcomes.

CONCLUSION

Adverse SDoH is associated with poor LN outcomes. Having two or more adverse SDoH, specifically in different SDoH domains, had a multiplicative impact leading to worse LN outcomes, widening disparities.

Receipt of rheumatology care and lupus-specific labs among young adults with systemic lupus erythematosus: A US Medicare retention in care cohort study

OBJECTIVE

In systemic lupus erythematosus, poor disease outcomes occur in young adults, patients identifying as Black or Hispanic, and socioeconomically disadvantaged patients. These identities and social factors differentially shape care access and quality that contribute to lupus health disparities in the US. Thus, our objective was to measure markers of care access and quality, including rheumatology visits (longitudinal care retention) and lupus-specific serology testing, by race and ethnicity, neighborhood disadvantage, and geographic context.

METHODS

This cohort study used a geo-linked 20% national sample of young adult Medicare beneficiaries (ages 18-35) with lupus-coded encounters and a 1-year assessment period. Retention in lupus care required a rheumatology visit in each 6-month period, and serology testing required ≥1 complement or dsDNA antibody test within the year. Multivariable logistic regression models were fit for visit-based retention and serology testing to determine associations with race and ethnicity, neighborhood disadvantage, and geography.

RESULTS

Among 1,036 young adults with lupus, 39% saw a rheumatologist every 6 months and 28% had serology testing. White beneficiaries from the least disadvantaged quintile of neighborhoods had higher visit-based retention than other beneficiaries (64% vs 30%-60%). Serology testing decreased with increasing neighborhood disadvantage quintile (aOR 0.80; 95% CI 0.71, 0.90) and in the Midwest (aOR 0.46; 0.30, 0.71).

CONCLUSION

Disparities in care, measured by rheumatology visits and serology testing, exist by neighborhood disadvantage, race and ethnicity, and region among young adults with lupus, despite uniform Medicare coverage. Findings support evaluating lupus care quality measures and their impact on US lupus outcomes.

Racial and Ethnic Composition of Populations Served by Freestanding Children's Hospitals and Disparities in Outcomes of Pediatric Lupus

OBJECTIVE

Health disparities may be driven by hospital-level factors. We assessed whether racial and ethnic composition of populations hospitals serve explain or modify disparities in hospital outcomes of children with systemic lupus erythematosus (SLE).

METHODS

In this retrospective cohort study of patients 5 to 26 years old with SLE at 47 children's hospitals in the Pediatric Health Information System (2006-2021), race and ethnicity were assessed at the patient level and hospital level (proportion of total admissions composed of Black or Hispanic patients, respectively). Outcomes included intensive care unit (ICU) admission or adverse renal outcome (end-stage renal disease, dialysis, or transplant) during follow-up. We estimated racial and ethnic disparities, adjusted or stratified by hospital racial or ethnic composition.

RESULTS

Of 8,125 patients with SLE, 2,293 (28%) required ICU admission, and 698 (9%) had an adverse renal outcome. Black and non-Hispanic White disparities in ICU admission were observed only at hospitals serving higher proportions of Black patients (odds ratio [OR] 1.29, 95% confidence interval [95% CI] 1.04-1.59 vs OR 1.07, 95% CI 0.83-1.38). Larger Black and non-Hispanic White disparities in adverse renal outcomes were observed at hospitals with higher Black racial composition (OR 2.0, 95% CI 1.4-2.8 vs OR 1.7, 95% CI 1.1-2.4). Conversely, Hispanic versus non-Hispanic disparities in renal outcomes persisted after adjustment for hospital-reported Hispanic ethnic composition but were observed only at hospitals with lower proportions of Hispanic patients.

CONCLUSION

Worse Black and White disparities in SLE outcomes are observed at children's hospitals serving more Black children, whereas distinct patterns are observed for Hispanic and non-Hispanic disparities. Reporting of hospital characteristics related to populations served is needed to identify modifiable drivers of hospital-level variation.

Systemic lupus erythematosus in American Indian/Alaska natives: Incorporating our new understanding of the biology of trauma

OBJECTIVE

To review the literature regarding systemic lupus erythematosus (SLE) in American Indian/Alaska Native (AI/AN) people and relate prevalence and/or disease severity to our emerging understanding of the biology of trauma and toxic stress.

METHODS

We conducted a search and review of the literature using search terms "lupus and American Indians" "ACEs and disease outcome" "Biology of Adversity" "lupus and ACE scores," " lupus and childhood abuse." These search criteria were entered into Google Scholar and articles retrieved from PubMed, NBCI. This approach yielded a small numbers of papers used throughout this review. We excluded articles that were not published in a peer reviewed journals, as well as editorial commentaries.

RESULTS

In the AI/AN population, SLE shows high prevalence rates and severe disease manifestations, comparable to the African American population. AI/AN populations also have high rates of childhood trauma. Toxic stress and trauma such as those catalogued in the Adverse Childhood Experiences (ACE) study have broad-reaching immunologic and epigenetic effects that are likely to be relevant to our understanding of SLE in AI/AN people.

CONCLUSIONS

AI/AN people have high rates of SLE. These high rates are likely to be driven by many complex factors, not all of which are genetic. Future research is needed to establish (or refute) a causal connection between the biology of adversity and SLE in socially marginalized and historically traumatized populations.

Cytotoxic T-lymphocyte associated protein 4 (CTLA4) polymorphisms are linked to systemic lupus erythematosus: an updated meta-analysis

Cytotoxic T-lymphocyte associated protein 4 (CTLA-4) molecule controls T cell immune response. Functional single nucleotide polymorphisms (SNPs) in the CTLA-4 gene have been associated with several autoimmune diseases, including systemic lupus erythematosus (SLE).  However, the genetic association of the CTLA-4 variants with vulnerability to SLE remained contradictory. We have conducted a current meta-analysis by combining the findings of prior published articles in order to make a conclusive statement. Various literature databases were screened with appropriate keywords to obtain relevant articles, and eligible reports were obtained using well-defined inclusion and exclusion criteria. Meta-analysis was performed by Comprehensive Meta-analysis V 3.3, and various statistical parameters such as odds ratio, 95% confidence interval, and probability values were computed. A total of 3847 SLE patients and 5278 healthy controls were considered in the present meta-analysis from 26 individual reports. A significant association of CTLA-4 +49 A/G (G vs. A: p=0.03, OR=1.47) and -1722 T/C (p=0.02, OR=0.87) polymorphisms were observed with susceptibility and resistance against the development of SLE, respectively. However, the other two SNPs in the CTLA-4 gene (-318 C/T and -1661 A/G) failed to establish a connection. Interestingly, subgroup analysis revealed an association of CTLA-4 +49 A/G with a predisposition to SLE only in the Asian population (G vs. A: p=0.04, OR=1.26, GG vs. AA: p=0.02, OR=1.84, AG vs AA: p=0.01, OR=1.44, GG+AG vs AA: p=0.01, OR=1.52) and not in Caucasians. The current meta-analysis suggests a significant CTLA-4 +49 A/G variant association with susceptibility to SLE development in overall and Asian populations. In contrast, the other variant, -1722 T/C, is linked with protection against SLE. However, further case-control studies in diverse ethnic populations are requisite.

Exposure of Akwesasne Mohawk women to polychlorinated biphenyls and hexachlorobenzene is associated with increased serum levels of thyroid peroxidase autoantibodies

Persistent organic pollutants (POPs) including polychlorinated biphenyls (PCBs), hexachlorobenzene (HCB), and dichlorodiphenyltrichloroethane (p,p'-DDT) were reported to influence immunological activity. As endocrine-disrupting chemicals (EDC), these pollutants may disrupt normal thyroid function and act as catalysts for development of autoimmune thyroid disease by directly and indirectly affecting levels of thyroid peroxidase antibodies (TPOAbs). Native American communities are disproportionately exposed to harmful toxicants and are at an increased risk of developing an autoimmune disease. The aim of this study was to determine the association between POPs and TPOAbs in serum obtained from Native American women. This assessment was used to measure whether increased risk of autoimmune thyroid disease occurred as a result of exposure to POPs. Data were collected from 183 Akwesasne Mohawk women, 21-38 years of age, between 2009 and 2013. Multivariate analyses were conducted to determine the association between toxicant exposure and levels of TPOAbs. In multiple logistic regression analyses, exposure to PCB congener 33 was related to elevated risk of individuals possessing above normal levels of TPOAbs. Further, HCB was associated with more than 2-fold higher risk of possessing above normal levels of TPOAbs compared to women with normal levels of TPOAbs. p,p'-DDE was not associated with TPOAb levels within this study. Exposure to PCB congener 33 and HCB was correlated with above normal levels of TPOAbs, a marker of autoimmune thyroid disease. Additional investigations are needed to establish the causes and factors surrounding autoimmune thyroid disease which are multiple and complex.

Human Skin Pigmentation: From a Biological Feature to a Social Determinant

Skin pigmentation is the most variable human characteristic that can be observed and has been used throughout history to classify humans into distinct groups. Many factors influence skin colour, but the melanin pigment is considered the most important because its type and quantity can determine variations in pigmentation shades. The evolution of skin pigmentation started around 1.6-2 million years ago. As a result of migratory phenomena to places with less ultraviolet radiation (UVR) and other seasonal regimes, the selection of depigmented skin and different tanning capabilities occurred over time. Thus, genetic adaptation to new environmental conditions gradually led to changes in skin pigmentation. Despite the biological importance of pigmentation, variation in skin colour has led to social and health inequalities. Since Linnaeus, skin colour classifications have been used to describe different human groups, encouraging the misuse of a biological characteristic. This review examines the characterisation of pigmentation and its evolution through history and society. The unequal perception of pigmentation diversity has led to an incomplete state of dermatological training and issues in medical approach in dermatology. The consciousness of all these aspects increases the need to address and overcome dermatologic and social health disparities related to skin pigmentation.

Racial disparities in pregnancy outcomes among women with rheumatic diseases: A systematic literature review

OBJECTIVE

There is a limited understanding of racial disparities in adverse pregnancy outcomes (APO) among women with rheumatic diseases. The aim of our study was to conduct a systematic literature review to evaluate the impact of race on APO in women with rheumatic diseases.

METHODS

Databases were searched to find reports of APO stratified by race among women with rheumatic diseases. The initial searches were conducted in July 2020 and updated in March 2021. Of the final included articles, the full text was reviewed, and data was extracted from each study using a standard data abstraction form.

RESULTS

Ten studies with a total of 39,720 patients met our eligibility criteria. There was a greater propensity for APO in racial minorities with rheumatic diseases compared to their White counterparts. Among women with systemic lupus erythematosus (SLE), Black women had the highest odds of APOs, particularly those with a concomitant diagnosis of antiphospholipid syndrome. Pooled meta-analysis could not be done due to multiple factors, including heterogeneity between studies.

CONCLUSION

Racial minorities with rheumatic diseases are more prone to APO compared to their White counterparts. One limitation is the lack of standardized criteria for APO, which prohibited direct comparison between studies. There is also a paucity of data looking at APOs among women with rheumatic diseases other than SLE. Further research is needed to explore the drivers of these racial disparities to guide targeted solutions for those in the greatest need.

Differences in Multi-Dimensional Well-Being Among Factory Workers: Evidence from Six Countries

This paper presents cross-cultural comparisons of well-being among factory workers, as measured by the six well-being domains of happiness and life satisfaction, physical and mental health, meaning and purpose, character and virtue, close social relationships, and financial and material stability. Relative ranks of well-being domains across examined groups of workers are also compared. Results are based on survey data from factory workers in Cambodia, China, Mexico, Poland, Sri Lanka, and the United States. Average well-being scores are higher among factory workers in Mexico, China, and Cambodia than in the U.S., Poland, and Sri Lanka across all domains except financial and material stability. Close social relationships were the highest ranked domain in Cambodia and China but ranked much lower (5th) in the U.S. Meaning and purpose, as well as character and virtue were highly ranked across the board. Strong social relationships seem to thrive in contexts where financial insecurity is high.

An ecological approach to understanding and addressing health inequities of systemic lupus erythematosus

Systemic Lupus Erythematosus (SLE) is a complex chronic autoimmune disease disproportionally afflicting women and, in particular, American Indian/Alaska Native, Black, and Hispanic women. These groups of women have significantly worse SLE-related health outcomes which are partially attributable to their exposure to marginalizing and interconnecting social issues like racism, sexism, economic inequality, and more. Although these groups of women have higher rates of SLE and though it is well known that they are at risk of exposure to marginalizing social phenomena, relatively little SLE literature explicitly links and addresses the relationship between marginalizing social issues and poor SLE-health outcomes among these women. Therefore, we developed a community-engaged partnership with two childhood-SLE diagnosed women of color to identify their perspectives on which systemic issues impacted on their SLE health-related outcomes. Afterward, we used Cochrane guidelines to conduct a rapid review associated with these identified issues and original SLE research. Then, we adapted an ecological model to illustrate the connection between systems issues and SLE health outcomes. Finally, we provided recommendations for ways to research and clinically mitigate SLE health inequities.

Racial differences in persistent glucocorticoid use patterns among medicaid beneficiaries with incident systemic lupus erythematosus

OBJECTIVE

Glucocorticoids ("steroids") are frequently used in systemic lupus erythematosus (SLE). Prolonged use may contribute to racial/ethnic disparities in avoidable adverse outcomes. We examined racial/ethnic differences in longitudinal patterns of steroid use and dose.

METHODS

We identified Medicaid beneficiaries 18-65 years with incident SLE who received steroids for 12 months following the index date. Group-based trajectory modeling was used to identify patterns of daily prednisone-equivalent steroid doses. We examined demographic, clinical and healthcare utilization factors during the baseline period and used multinomial logistic regression to estimate the odds of belonging to the higher vs. lowest steroid dose trajectories over time.

RESULTS

We identified 6314 individuals with SLE with ≥1 dispensed steroid prescription. The mean (SD) prednisone-equivalent dose was 7 (23) mg/day for Black, 7 (26) for Hispanic, 7 (13) for Asian, and 4 (10) for White individuals. Adjusted multinomial models demonstrated higher odds of belonging to the highest vs. lowest steroid trajectory for Black (OR 2.07, 95% CI 1.65-2.61), Hispanic (OR 1.81, 95% CI 1.38-2.39), and Asian (OR 2.42, 95% CI 1.53-3.83) vs. White individuals. Having >5 outpatient visits during the baseline period was associated with lower odds of being in the persistently high-dose steroid trajectory (OR 0.77; 95% CI 0.60-0.98).

CONCLUSION

Black, Hispanic, and Asian (vs. White) individuals had higher odds of persistently high-dose steroid use. Sustained access to outpatient care and the development of standardized steroid-tapering regimens from clinical trials with diverse populations may be targets for intervention to mitigate disparities in steroid-related adverse outcomes.

Comparison of Contributors to Mortality Differences in SLE Patients with Different Initial Disease Activity: A Larger Multicenter Cohort Study

To explore the etiology of risk factors and quantify the mortality differences in systemic lupus erythematosus (SLE) patients with different initial disease activity. The Jiangsu Lupus database was established by collecting medical records from first-hospitalized SLE patients during 1999-2009 from 26 centers in Jiangsu province, China, and their survival status every five years. The initial SLEDAI scores [high (>12) vs. low-moderate (≤12)] differences in mortality attributable to risk factors were quantified using population attributable fraction (PAF), relative attributable risk (RAR) and adjusted relative risk (ARR). Among 2446 SLE patients, 83 and 176 deaths were observed in the low-moderate and high activity groups, with mortality rates of 7.7 and 14.0 per 1000 person years, respectively. Anemia was the leading contributor to mortality, with PAFs of 40.4 and 37.5 in the low-moderate and high activity groups, respectively, and explained 23.2% of the mortality differences with an ARR of 1.66 between the two groups. Cardiopulmonary involvement caused the highest PAFs in the low-moderate (20.5%) and high activity (13.6%) groups, explaining 18.3% of the mortality differences. The combination of anemia and cardiopulmonary involvement had the highest RAR, causing 39.8% of the mortality differences (ARR = 1.52) between the two groups. In addition, hypoalbuminemia and a decrease in the creatinine clearance rate accounted for 20-30% of deaths and explained 10-20% of the mortality differences between the two groups, while antimalarial drug nonuse accounted for about 35% of deaths and explained 3.6% of the mortality differences. Anemia, cardiopulmonary involvement and hypoalbuminemia may cause substantial mortality differences across disease activity states, suggesting additional strategies beyond disease activity assessment to monitor SLE outcomes.

Social determinants of depression in systemic lupus erythematosus: A systematic scoping review

Social determinants of health (SDOH) influence inequities in systemic lupus erythematosus (SLE). While these inequities contribute to overall disease experience, there is little consensus guiding our understanding of the psychological implications of SDOH in SLE. Given the paucity of evidence in this area, the aim of this scoping review was to systematically assess the volume and features of available research literature on associations of SDOH with depression in SLE over the past 20 years, from 1 January 2000 to 16 November 2021. We developed a search strategy for PubMed and EMBASE that included keywords for depression and lupus. After screening 2188 articles, we identified 22 original articles that met our inclusion criteria. At least one SDOH was associated with depression in two of the six studies with unadjusted estimates and 13 of the 16 studies with adjusted estimates. Results provide consistent but sparse evidence that SDOH are associated with depression in SLE. Additionally, depression epidemiology in SLE may differ from the general population such that depression risk is more similar across genders and racial/ethnic groups. More work is needed to identify the SDOH that have the greatest impact on depression and mental health among SLE patients, as well as how and when to intervene.

Representation of Skin Colors in Images of Patients With Lupus

OBJECTIVE

Lupus presents earlier and more severely among patients with skin of color (SOC), and this population experiences worse outcomes. Providers rely on medical education materials when developing skills to care for patients, yet these resources historically underrepresent patients with SOC and marginalize vulnerable populations. In this study, we investigated if this publication bias extends to images depicting patients with lupus.

METHODS

We reviewed published images of patients with lupus from rheumatology, dermatology, and internal medicine textbooks and medical journals, SOC atlases, online image libraries, UpToDate, and Google Images. We selected materials published from 2014 to 2019 that were available through our university's online medical library. We used the search terms "lupus" and "lupus rash" to identify images. We rated the skin color in each image using the New Immigrant Survey Skin Color Scale and categorized them as light, medium, or dark. We compared the frequencies of published skin tones with chi-square and odds ratio analyses.

RESULTS

We assessed the skin tone of 1,417 images. The significant majority (56.4%) of the images represented light skin (χ²  = 490.14, P < 0.001). After SOC atlases, journals were the most inclusive of images depicting dark skin tones. The specialty of dermatology was most inclusive of medium and darker skin tones.

CONCLUSION

Published images of lupus underrepresent patients with SOC, which may limit providers' ability to deliver care to the patients who are at greatest risk for complications.

Skin Tone, Race/Ethnicity, and Gender Differences in BMI among New US Immigrants

Scholars have been interested in the relationship between skin tone and health since at least the 1970s; however, no study, to our knowledge, has analyzed a diverse immigrant sample. In this study, we use the New Immigrant Survey and interactions to examine how skin tone and race/ethnicity - alongside gender - jointly pattern BMI among Legal Permanent Residents. Our approach allows for the analysis of BMI among multiple racial/ethnic immigrant groups, while considering skin tone. Our results document that darker skin shades are associated with higher BMI, but only for women. Further, we also tease out the relationship between gender and race/ethnicity for BMI, which allows us to better understand this critical connection for new immigrants' health in the United States. Together, our results highlight that BMI jointly varies by skin tone and race/ethnicity, which emphasizes the importance of an intersectional approach, especially for new immigrant women of color.

Demographic Predictors of Complete Well-Being

This paper examines demographic differences in flourishing, defined as "complete well-being" and consisting of six domains: emotional health, physical health, purpose, character strengths, social connectedness, and financial security. Results are based on a random, cross-sectional sample of 2363 survey respondents drawn from employees of a large, national, self-insured employer based in the United States. We found that well-being across domains tends to increase with age, although there are some variations. Results are similar across most domains for men and women, although women score higher on character strengths, while men had higher scores on financial security. Racial and ethnic differences were striking. Black employees score higher than the reference group (White employees) on the emotional, purpose, and character strengths domains, but considerably lower on financial security. Hispanics also score lower on financial security (though not as low as Blacks), but higher than Whites on purpose, character strengths, and social connectedness. Asians reported higher well-being than Whites across all domains except purpose.

Associations between autoimmune dysfunction and pollutants in Akwesasne Mohawk women: Dichlorodiphenyltrichloroethane and polychlorinated biphenyl exposure

BACKGROUND

Pollutant exposures, including polychlorinated biphenyls (PCBs) and dichlorodiphenyltrichloroethane (DDT), have been found to disrupt normal immune function. Native American communities are disproportionately affected by autoimmune dysfunction and are more likely to be exposed to harmful pollutants than the general population.

OBJECTIVE

To determine the association between autoimmune dysfunction and pollutant exposure levels, this study evaluates the statistical relationship between the presence of autoimmune dysfunction and pollutant exposure.

METHODS

Information was collected from Akwesasne Mohawk women (n = 182), 21-39 years of age, between 2009 and 2013. Data collection included anthropometric measurements, medical diagnoses of autoimmune disease and symptoms of autoimmune dysfunction in the medical record, and blood draws for measurement of pollutants. Multivariate analyses determined the association between toxicant exposure and autoimmune dysfunction.

RESULTS

Toxicant p,p'-DDE was positively associated with an almost two-fold risk of autoimmune dysfunction. p,p'-DDE and PCB congeners 32, 136, and 138 were positively associated in a multivariate analysis with an autoimmune diagnosis.

CONCLUSIONS

Pollutant exposures, specifically to p,p'-DDE and some PCB congeners, are common exposures that are associated with autoimmune dysfunction and autoimmune disease, although there are other factors and causes related to autoimmune dysfunction incidence.

Good Long-Term Prognosis of Lupus Nephritis in the High-Income Afro-Caribbean Population of Martinique with Free Access to Healthcare

Lupus nephritis (LN) has been described as having worse survival and renal outcomes in African-descent patients than Caucasians. We aimed to provide long-term population-based data in an Afro-descendant cohort of LN with high income and easy and free access to specialized healthcare. Study design: We performed a retrospective population-based analysis using data from 2002–2015 of 1140 renal biopsies at the University Hospital of Martinique (French West Indies). All systemic lupus erythematosus patients with a diagnosis of LN followed for at least 12 months in Martinique or who died during this period were included. Results: A total of 89 patients were included, of whom 68 (76.4%) had proliferative (class III or IV), 17 (19.1%) had membranous (class V), and 4 (4.5%) had class I or II lupus nephritis according to the ISN/RPS classification. At a mean follow-up of 118.3 months, 51.7% of patients were still in remission. The rates of end-stage renal disease were 13.5%, 19.1%, and 21.3% at 10, 15, and 20 years of follow-up, respectively, and mortality rates were 4.5%, 5.6%, and 7.9% at 10, 15, and 20 years of follow-up, respectively. Conclusions: The good survival of our Afro-descendant LN patients, similar to that observed in Caucasians, shades the burden of ethnicity but rather emphasizes and reinforces the importance of optimizing all modifiable factors associated with poor outcome, especially socioeconomics.

The role of MBL, PCT, CRP, neutrophil-lymphocyte ratio, and platelet lymphocyte ratio in differentiating infections from flares in lupus

BACKGROUND

The distinction between infection and flare in systemic lupus erythematosus (SLE) has always been a dilemma for clinicians as the clinical and biochemical profiles overlap. The present study evaluated affordable biomarkers to distinguish infection from flare in an SLE cohort in a tertiary care center in eastern India.

METHODS

One hundred and fifty-two SLE patients were clinically evaluated and enrolled in the present study. Hematological, immunological, and biochemical profiles and various biomarkers such as C reactive protein (CRP), procalcitonin (PCT), and Mannose-binding lectin (MBL) were quantified.

RESULTS

One hundred and fifty-two patients (152) were enrolled in the present study and all had SLEDAI scores of more than 4. From which 70 had infection, and the common infections were urinary tract infection (34.28%) followed by pneumonia (27.14%). Neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP) were significantly elevated in SLE with infections (NLR: 5.84 ± 2.47; CRP: 30.56 ± 41.63) than those with flare (NLR: 3.87 ± 2.62; CRP: 8.73 ± 9.53). The receiver operating characteristic curve (ROC) analysis revealed CRP, PLR, and NLR as important markers for predicting infections (CRP: AUC = 0.682, p = 0.0001; PLR: AUC = 0.668, p = 0.0008; NLR: AUC = 0.742, p < 0.0001). The MBL and PCT levels were comparable among SLE flare and those with infections.

CONCLUSIONS

NLR and CRP levels are affordable biomarkers to distinguish infections from flares in SLE. MBL and PCT could not differentiate flare from an infection. Key Points • Biomarkers for the differentiation of infection and flare in SLE are limited. • NLR, PLR, and CRP are promising biomarkers to enable differentiation. • PCT and MBL are not ideal biomarkers to differentiate infection from flare.

Cardiovascular Implications of Immune Disorders in Women

Immune responses differ between men and women, with women at higher risk of developing chronic autoimmune diseases and having more robust immune responses to many viruses, including HIV and hepatitis C virus. Although immune dysregulation plays a prominent role in chronic systemic inflammation, a key driver in the development of atherosclerotic cardiovascular disease (ASCVD), standard ASCVD risk prediction scores underestimate risk in populations with immune disorders, particularly women. This review focuses on the ASCVD implications of immune dysregulation due to disorders with varying global prevalence by sex: autoimmune disorders (female predominant), HIV (male-female equivalent), and hepatitis C virus (male predominant). Factors contributing to ASCVD in women with immune disorders, including traditional risk factors, dysregulated innate and adaptive immunity, sex hormones, and treatment modalities, are discussed. Finally, the need to develop new ASCVD risk stratification tools that incorporate variables specific to populations with chronic immune disorders, particularly in women, is emphasized.

Hospitalisation for systemic lupus erythematosus associates with an increased risk of mortality in Australian patients from 1980 to 2014: a longitudinal, population-level, data linkage, cohort study

Objective

Mortality rates for patients with SLE have not been reported in Australia. This study determined the association between a hospitalisation for SLE with mortality.

Methods

Population-level cohort study of patients with SLE (n=2112; 25 710 person-years) and general population comparators (controls) (n=21, 120; 280 637 person-years) identified from hospital records contained within the WA Rheumatic Disease Epidemiological Registry from 1980 to 2013. SLE was identified by ICD-9-CM: 695.4, 710.0, ICD-10-AM: L93.0, M32.0. Controls were nearest matched (10:1) for age, sex, Aboriginality and temporality. Using longitudinal linked health data, we assessed the association between a hospitalisation for SLE mortality and mortality with univariate and multivariate Cox proportional hazards and competing risks regression models.

Results

At timezero, patients with SLE were similar in age (43.96 years), with higher representation of females (85.1% vs 83.4%, p=0.038), Aboriginal Australians (7.8% vs 6.0%) and smokers (20.5% vs 13.2%). Before study entry, patients with SLE (mean lookback 9 years) had higher comorbidity accrual (Charlson Comorbidity Index ≥1 item (42.0% vs 20.5%)), especially cardiovascular disease (CVD) (44.7% vs 21.0%) and nephritis (16.4% vs 0.5%), all p<0.001. During follow-up (mean 12.5 years), 548 (26.0%) patients with SLE and 2450 (11.6%) comparators died. A hospitalisation for SLE increased the unadjusted (HR 2.42, 95% CI 2.20 to 2.65) and multivariate-adjusted risk of mortality (aHR 2.03, 95% CI 1.84 to 2.23), which reduced from 1980 to 1999 (aHR 1.42) to 2000–2014 (aHR 1.27). Females (aHR 2.11), Aboriginal Australians (aHR 3.32), socioeconomically disadvantaged (aHR 2.49), and those <40 years old (aHR 7.46) were most vulnerable. At death, patients with SLE had a higher burden of infection (aHR 4.38), CVD (aHR 2.09) and renal disease (aHR 3.43), all p<0.001.

Conclusions

A hospitalisation for SLE associated with an increased risk of mortality over the 1980–2014 period compared with the general population. The risk was especially high in younger (<40 years old), socioeconomically disadvantaged and Aboriginal Australians.

Global epidemiology of systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune disease with protean manifestations that predominantly affects young women. Certain ethnic groups are more vulnerable than others to developing SLE and experience increased morbidity and mortality. Reports of the global incidence and prevalence of SLE vary widely, owing to inherent variation in population demographics, environmental exposures and socioeconomic factors. Differences in study design and case definitions also contribute to inconsistent reporting. Very little is known about the incidence of SLE in Africa and Australasia. Identifying and remediating such gaps in epidemiology is critical to understanding the global burden of SLE and improving patient outcomes. Mortality from SLE is still two to three times higher than that of the general population. Internationally, the frequent causes of death for patients with SLE include infection and cardiovascular disease. Even without new therapies, mortality can potentially be mitigated with enhanced quality of care. This Review focuses primarily on the past 5 years of global epidemiological studies and discusses the regional incidence and prevalence of SLE and top causes of mortality.

Mortality Among Hospitalized Individuals With Systemic Lupus Erythematosus in the US Between 2006 and 2016

OBJECTIVE

To evaluate time trends in mortality for hospitalized adults with systemic lupus erythematosus (SLE) compared to the general hospitalized population (GHP), and to identify factors associated with increased risk of death among hospitalized SLE patients.

METHODS

We used the National (Nationwide) Inpatient Sample to estimate all-cause mortality for adults discharged from community hospitals in the US between 2006 and 2016. Poisson regression models were used to estimate the risk of in-hospital death among all patients, including demographic characteristics, socioeconomic factors, comorbidity score, hospital region, SLE diagnosis, and race/ethnicity as covariates.

RESULTS

Among 340,467,049 hospitalizations analyzed, 1,903,279 had a discharge diagnosis of SLE. In adjusted analysis, the risk of inpatient death decreased among hospitalizations for patients with SLE from 2.2% to 1.5% (P < 0.001) between 2006 and 2016. All of the decrease in SLE mortality occurred between 2006 and 2008; after 2008, mortality stabilized at a rate statistically similar to the GHP. Hospitalizations for Black, Hispanic, and Asian/Pacific Islander patients with SLE were more likely to end in death compared to hospitalizations for either White patients with SLE or individuals of the same non-White race/ethnicity without SLE.

CONCLUSION

In the largest study of in-hospital SLE mortality published to date, we found significant improvements in mortality for hospitalized patients with SLE in the US from 2006 until 2008, after which mortality stabilized at a level similar to that of the GHP. Our results also demonstrate a persistently high mortality burden among Black and Hispanic patients with SLE in the US and contribute new data revealing high mortality among Asian/Pacific Islander patients with SLE.

Comparative risks of cardiovascular disease events among SLE patients receiving immunosuppressive medications

OBJECTIVES

SLE patients have elevated cardiovascular disease (CVD) risk, but it is unclear whether this risk is affected by choice of immunosuppressive drug. We compared CVD risks among SLE patients starting MMF, CYC or AZA.

METHODS

Using Medicaid Analytic eXtract (2000-2012), adult SLE patients starting MMF, CYC or AZA were identified and propensity scores (PS) were estimated for receipt of MMF vs CYC and MMF vs AZA. We examined rates of first CVD event (primary outcome), all-cause mortality, and a composite of first CVD event and all-cause mortality (secondary outcomes). After 1:1 PS-matching, Fine-Gray regression models estimated subdistribution hazard ratios (HRs.d.) for risk of CVD events. Cox regression models estimated HRs for all-cause mortality. The primary analysis was as-treated; 6- and 12-month intention-to-treat (ITT) analyses were secondary.

RESULTS

We studied 680 PS-matched pairs of patients with SLE initiating MMF vs CYC and 1871 pairs initiating MMF vs AZA. Risk of first CVD event was non-significantly reduced for MMF vs CYC [HRs.d 0.72 (95% CI: 0.37, 1.39)] and for MMF vs AZA [HRs.d 0.88 (95% CI: 0.59, 1.32)] groups. In the 12-month ITT, first CVD event risk was lower among MMF than AZA new users [HRs.d 0.68 (95% CI: 0.47, 0.98)].

CONCLUSION

In this head-to-head PS-matched analysis, CVD event risks among SLE patients starting MMF vs CYC or AZA were not statistically reduced except in one 12-month ITT analysis of MMF vs AZA, suggesting longer-term use may convey benefit. Further studies of potential cardioprotective benefit of MMF are necessary.

Systemic Lupus Erythematosus and Critical Illness

Systemic lupus erythematosus is a chronic autoimmune disorder that causes a wide range of mild to life-threatening conditions that require hospitalization and critical care. The morbidity and mortality of systemic lupus erythematosus are associated with the organ system damage caused by intermittent or chronic disease activity and with the complications of long-term and toxic immunosuppressant medication regimens. This article reviews the epidemiologic, clinical, diagnostic, and therapeutic information essential for critical care clinicians who provide care to patients with systemic lupus erythematosus.

An Ethnic Variation in the Acceptance of Biological Disease-Modifying Therapies: A University Hospital Experience

Ethnic variations in the outcomes of rheumatological diseases are well documented. While physiological differences may account for these disparities, attitude to treatment is also likely to be a significant modifiable contributor. We sought to determine if an ethnic variation exists in the uptake of biological disease-modifying anti-rheumatic drugs (DMARD) among a multi-ethnic cohort when offered in-person through a healthcare system free at the point of access. We conducted a retrospective cross-sectional study of patients seen in a biologic therapy counselling clinic between December 2016 and April 2017. Clinic letters from consultations were reviewed, and data including ethnicity, language spoken, and decision to accept or reject the therapy were extracted. We chose to measure uptake over adherence, as we believe it is an earlier, more direct marker of attitudes to joint saving medications. Ninety-one cases were included in the analysis. Over 13.2% (12/91) of the cohort declined a biologic treatment when it was offered as the standard of care for joint disease. Non-Caucasian patients accepted treatment less often than Caucasian (White British) patients (OR 0.265, CI 0.73-0.959, p = 0.043), as did those who did not speak English as a first language (OR 0.094, CI 0.18-0.497, p = 0.005). Age, sex, and diagnosis were well matched between those who accepted and declined therapy. We demonstrate a disparity in the uptake of biologic therapies between the White British population and patients from other ethnicities. The reasons for this are likely multifactorial and could be related to socio-economic factors, language barriers, and cultural differences. Addressing this discrepancy is a crucial first step to tackling preventable disparities in the outcomes of rheumatological disease between different ethnicities.

Evaluation of structured data from electronic health records to identify clinical classification criteria attributes for systemic lupus erythematosus

Objective

Our objective was to develop algorithms to identify lupus clinical classification criteria attributes using structured data found in the electronic health record (EHR) and determine whether they could be used to describe a cohort of people with lupus and discriminate them from a defined healthy control cohort.

Methods

We created gold standard lupus and healthy patient cohorts that were fully adjudicated for the American College of Rheumatology (ACR), Systemic Lupus International Collaborating Clinics (SLICC) and European League Against Rheumatism/ACR (EULAR/ACR) classification criteria and had matched EHR data. We implemented rule-based algorithms using structured data within the EHR system for each attribute of the three classification criteria. Individual criteria attribute and classification criteria algorithms as a whole were assessed over our combined cohorts and the overall performance of the algorithms was measured through sensitivity and specificity.

Results

Individual classification criteria attributes had a wide range of sensitivities, 7% (oral ulcers) to 97% (haematological disorders) and specificities, 56% (haematological disorders) to 98% (photosensitivity), but all could be identified in EHR data. In general, algorithms based on laboratory results performed better than those primarily based on diagnosis codes. All three classification criteria systems effectively distinguished members of our case and control cohorts, but the SLICC criteria-based algorithm had the highest overall performance (76% sensitivity, 99% specificity).

Conclusions

It is possible to characterise disease manifestations in people with lupus using classification criteria-based algorithms that assess structured EHR data. These algorithms may reduce chart review burden and are a foundation for identifying subpopulations of patients with lupus based on disease presentation to support precision medicine applications.

Downregulated Serum Exosomal miR-451a Expression Correlates With Renal Damage and Its Intercellular Communication Role in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a multi-system autoimmune disease characterized by continuous inflammation and the production of autoantibodies. Exosomes, acting as a critical tool for communication between cells, are involved in the pathogenesis of SLE, particularly in inflammation and immune imbalance. In this study, we aimed to extract and confirm the pro-inflammatory effect of serum exosomes in SLE. Then, we attempted to find differentially expressed exosomal microRNAs in the serum of healthy subjects and SLE patients via miRNA microarray analysis and validated the target exosomal microRNA, exosomal miR-451a, which expression level decreased in serum of SLE patients by RT-qPCR. Furtherly, we analyzed the correlation between exosomal miR-451a and disease activity, kidney damage and typing, and traditional medicine therapy. Finally, we investigated the intercellular communication role of exosomal miR-451a in SLE by co-culture assay in vitro. Taken together, our study demonstrated that downregulated serum exosomal miR-451a expression correlated with SLE disease activity and renal damage as well as its intercellular communication role in SLE which provided potential therapeutic strategies.

Predictors of Adverse outcomes in patients with systemic lupus erythematosus transitioning to adult care

BACKGROUND

The transition from pediatric to adult care is a vulnerable period for individuals with chronic diseases. We sought to identify risk factors associated with poor outcomes in patients with childhood-onset systemic lupus erythematosus (cSLE) who have transitioned to adult care.

METHODS

A retrospective analysis of cSLE patients was performed. Outcomes of interest were development of end-stage renal disease (ESRD) or death and time to first hospitalization following final pediatric rheumatology visit. Multivariable logistic and Cox regression models were used.

RESULTS

Of 190 patients with cSLE, 21 (11%) developed ESRD and 9 (5%) died following the final pediatric rheumatology visit. In logistic regression, public insurance, history of Child Protective Services involvement, and an unscheduled hospitalization during the final year in pediatric care were predictive of ESRD or death (odds ratio (95% confidence intervals (CI)) 6.7 (1.5-30.7), 6.6 (2.3-19.1), and 3.2 (1.3-8.3), respectively). Among 114 patients with healthcare utilization data, 53% had a hospitalization in adult care. In Cox regression analysis, a pediatric outpatient opioid prescription was associated with shorter time to adult hospitalization and White or Asian race was associated with longer time to adult hospitalization (hazard ratio (CI) 3.5 (1.7-7.0) and 0.1 (0.03-0.4), respectively).

CONCLUSIONS

Risks factors associated with poor outcomes in adult care amongst patients with cSLE include public insurance, history of Child Protective Services involvement, unscheduled care utilization in pediatric care, pediatric outpatient opioid prescription, Black race and Hispanic ethnicity. Efforts to improve long-term outcomes among patients with cSLE should focus on these populations.

Development of a Set of Lupus-Specific, Ambulatory Care-Sensitive, Potentially Preventable Adverse Conditions: A Delphi Consensus Study

OBJECTIVE

Individuals with systemic lupus erythematosus (SLE) are at high risk for infections and SLE- and medication-related complications. The present study was undertaken to define a set of SLE-specific adverse outcomes that could be prevented, or their complications minimized, if timely, effective ambulatory care had been received.

METHODS

We used a modified Delphi process beginning with a literature review and key informant interviews to select initial SLE-specific potentially preventable conditions. We assembled a panel of 16 nationally recognized US-based experts from 8 subspecialties. Guided by the RAND-UCLA Appropriateness Method, we held 2 survey rounds with controlled feedback and an interactive webinar to reach consensus regarding preventability and importance on a population level for a set of SLE-specific adverse conditions. In a final round, the panelists endorsed the potentially preventable conditions.

RESULTS

Thirty-five potential conditions were initially proposed; 62 conditions were ultimately considered during the Delphi process. The response rate was 100% for both survey rounds, 88% for the webinar, and 94% for final approval. The 25 SLE-specific conditions meeting consensus as potentially preventable and important on a population level fell into 4 categories: vaccine-preventable illnesses (6 conditions), medication-related complications (8 conditions), reproductive health-related complications (6 conditions), and SLE-related complications (5 conditions).

CONCLUSION

We reached consensus on a diverse set of adverse outcomes relevant to SLE patients that may be preventable if patients receive high-quality ambulatory care. This set of outcomes may be studied at the health system level to determine how to best allocate resources and improve quality to reduce avoidable outcomes and disparities among those at highest risk.

Large-scale mortality gap between SLE and control population is associated with increased infection-related mortality in lupus

OBJECTIVE

The aim of the present study was to analyse the incidence, prevalence, mortality and cause of death data of adult SLE patients and matched controls in a full-populational, nationwide, retrospective study.

METHODS

This non-interventional study was based on database research of the National Health Insurance Fund of Hungary. A total of 7888 patients were included in the analyses, within which two subgroups of incident patients were created: the 'All incident SLE patients' group consisted of all incident SLE patients (4503 patients), while the 'Treated SLE patients' group contained those who received relevant therapy in the first 6 months after diagnosis (2582 patients).

RESULTS

The median age of the SLE population was found to be 46.5 years (women 85%). The incidence rate was 4.86 and 2.78 per 100 000 inhabitants in the 'All incident SLE patients' and 'Treated SLE patients' groups, respectively. The standardized mortality ratio was 1.63 and 2.09 in the 'All incident SLE patients' and 'Treated SLE patients' groups, respectively. Overall survival was significantly lower (P < 0.001) in both groups than in the general population, with hazard ratio = 2.17 in the 'All incident SLE patients' group and hazard ratio = 2.75 in the 'Treated SLE patients' group. There was no significant difference between SLE and control deaths regarding cerebrovascular conditions as the cause of death. Generally, cancer-related deaths were less common, while haematological cancer and infection-related deaths were more common in SLE patients.

CONCLUSION

Infections, especially sepsis, had the largest positive effect on top of the extra mortality of SLE. This highlights that SLE patients are at increased risk of infection-related death.

SARS-CoV-2 and Systemic Lupus Erythematosus

PURPOSE OF REVIEW

To summarize current knowledge of the impact of coronavirus disease 19 (COVID-19) on patients with systemic lupus erythematosus (SLE).

RECENT FINDINGS

Several observational studies, including case series, patient surveys, and patient registries, have examined the incidence and severity of COVID-19 in patients with SLE. Due to methodologic limitations (focus on sicker patients, exclusion of asymptomatic or mild cases, limited or inaccurate viral testing), it is difficult to determine the risk and outcomes of COVID-19 in SLE patients. Corticosteroids might be associated with increased hospitalizations from COVID-19 in individuals with autoimmune rheumatic diseases. Some immune suppressive treatments do not appear to significantly increase the risk of contracting COVID-19 or poor subsequent outcomes; however, data on the safety of specific drugs remain scarce. Studies in non-autoimmune cohorts have shown more severe COVID-19 in ethnic and racial minorities, populations also more heavily impacted by SLE. Such results have been attributed to highly prevalent socioeconomic disparities and comorbidities. The complex interplay between SARS-CoV-2 and the host immunologic milieu may have particular implications for patients with SLE that remain to be explored. Concerns have been raised of COVID-19 heightening the risk of thromboembolic events in the presence of an SLE-induced procoagulant state. Limitations in epidemiologic data available to date do not allow for assessing the risk and severity of COVID-19 in patients with SLE. Other than corticosteroids, prior use of some immune suppressive medications does not appear to increase the risk for infection with SARS-CoV-2 however, more comprehensive studies are needed.

Patterns of Healthcare Use and Medication Adherence among Youth with Systemic Lupus Erythematosus during Transfer from Pediatric to Adult Care

OBJECTIVE

Youth with systemic lupus erythematosus (SLE) transferring from pediatric to adult care are at risk for poor outcomes. We describe patterns of rheumatology/nephrology care and changes in healthcare use and medication adherence during transfer.

METHODS

We identified youth ages 15-25 with SLE using US private insurance claims from Optum's deidentified Clinformatics Data Mart. Rheumatology/nephrology visit patterns were categorized as (1) unilateral transfers to adult care within 12 months, (2) overlapping pediatric and adult visits, (3) lost to followup, or (4) continuing pediatric care. We used negative binomial regression and paired t tests to estimate changes in healthcare use and medication possession ratios (MPR) after the last pediatric (index) visit. We compared MPR between youth who transferred and age-matched peers continuing pediatric care.

RESULTS

Of the 184 youth transferred out of pediatric care, 41.8% transferred unilaterally, 31.5% had overlapping visits over a median of 12 months before final transfer, and 26.6% were lost to followup. We matched 107 youth continuing pediatric care. Overall, ambulatory care use decreased among those lost to followup. Acute care use decreased across all groups. MPR after the index date were lower in youth lost to followup (mean 0.24) compared to peers in pediatric care (mean 0.57, p < 0.001).

CONCLUSION

Youth with SLE with continuous private insurance coverage do not use more acute care after transfer to adult care. However, a substantial proportion fail to see adult subspecialists within 12 months and have worse medication adherence, placing them at higher risk for adverse outcomes.

Thrombotic Microangiopathy among Hospitalized Patients with Systemic Lupus Erythematosus in the United States

Background: This study aimed to evaluate thrombotic microangiopathy’s (TMA) incidence, risk factors, and impact on outcomes and resource use in hospitalized patients with systemic lupus erythematosus (SLE). Methods: We used the National Inpatient Sample to construct a cohort of hospitalized patients with SLE from 2003–2014. We compared clinical characteristics, in-hospital treatments, outcomes, and resource use between SLE patients with and without TMA. Results: Of 35,745 hospital admissions for SLE, TMA concurrently presented or developed in 188 (0.5%) admissions. Multivariable analysis showed that age ≥ 40 years and Hispanics were significantly associated with decreased risk of TMA, whereas Asian/Pacific Islanders and history of chronic kidney disease were significantly associated with increased risk of TMA. TMA patients required more kidney biopsy, plasmapheresis, mechanical ventilation, and renal replacement therapy. TMA was significantly associated with increased risk of in-hospital mortality and acute conditions including hemoptysis, glomerulonephritis, encephalitis/myelitis/encephalopathy, hemolytic anemia, pneumonia, urinary tract infection, sepsis, ischemic stroke, seizure, and acute kidney injury. The length of hospital stays and hospitalization cost was also significantly higher in SLE with TMA patients. Conclusion: TMA infrequently occurred in less than 1% of patients admitted for SLE, but it was significantly associated with higher morbidity, mortality, and resource use.

Bacterial infections in lupus: Roles in promoting immune activation and in pathogenesis of the disease

BACKGROUND

Bacterial infections of the lung, skin, bloodstream and other tissues are common in patients with systemic lupus erythematosus (lupus) and are often more severe and invasive than similar infections in control populations. A variety of studies have explored the changes in bacterial abundance in lupus patients, the rates of infection and the influence of particular bacterial species on disease progression, using both human patient samples and mouse models of lupus.

OBJECTIVE

The aim of this review is to summarize human and mouse studies that describe changes in the bacterial microbiome in lupus, the role of a leaky gut in stimulating inflammation, identification of specific bacterial species associated with lupus, and the potential roles of certain common bacterial infections in promoting lupus progression.

METHODS

Information was collected using searches of the Pubmed database for articles relevant to bacterial infections in lupus and to microbiome changes associated with lupus.

RESULTS

The reviewed studies demonstrate significant changes in the bacterial microbiome of lupus patients as compared to control subjects and in lupus-prone mice compared to control mice. Furthermore, there is evidence supporting the existence of a leaky gut in lupus patients and in lupus-prone mice. This leaky gut may allow live bacteria or bacterial components to enter the circulation and cause inflammation. Invasive bacterial infections are more common and often more severe in lupus patients. These include infections caused by Staphylococcus aureus, Salmonella enterica, Escherichia coli, Streptococcus pneumoniae and mycobacteria. These bacterial infections can trigger increased immune activation and inflammation, potentially stimulating activation of autoreactive lymphocytes and leading to worsening of lupus symptoms.

CONCLUSIONS

Together, the evidence suggests that lupus predisposes to infection, while infection may trigger worsening lupus, leading to a feedback loop that may reinforce autoimmune symptoms.

Patterns and predictors of recurrent acute care use among Medicaid beneficiaries with systemic lupus erythematosus

OBJECTIVES

We aimed to identify longitudinal patterns and predictors of acute care use (emergency department [ED] visits and hospitalizations) among individuals with SLE enrolled in Medicaid, the largest U.S. public insurance.

METHODS

Using Medicaid data (29 states, 2000-2010) we identified 18-65-year-olds with SLE (≥3 SLE ICD-9 codes, 3rd code=index date), ≥12 months of enrollment prior to the index date and ≥24 months post. For each 90-day interval post index date, patients were assigned binary indicators (1=≥1 ED visit or hospitalization, 0=none). We used group-based trajectory models to graph patterns of overall and SLE-specific acute care use, and multinomial logistic regression models to examine predictors.

RESULTS

Among 40,381 SLE patients, the mean age was 40.8 (SD 11.9). Using a three-group trajectory model, 2,342 (6%) were recurrent all-cause high acute care utilizers, 12,932 (32%) moderate, 25,107 (62%) infrequent; 25% were moderate or high utilizers for SLE. There were higher odds of all-cause, recurrent acute care use (vs. infrequent) among patients with severe vs. mild SLE (OR 3.37, 95% CI 3.0-3.78), chronic pain (odds ratio [OR] 1.63, 95% CI 1.15-2.32), depression (OR 1.90 95% CI 1.74-2.09), and cardiovascular disease (OR 2.29, 95% CI 2.08-2.52). Older age, male sex and hydroxychloroquine use were associated with lower odds of recurrent overall and SLE-specific acute care use.

CONCLUSION

Nearly 40% of Medicaid beneficiaries with SLE are recurrent all-cause acute care utilizers; 25% have recurrent use for SLE. Modifiable factors, including outpatient management of SLE and comorbidities, may reduce avoidable acute care use.

Disparities in Lupus and Lupus Nephritis Care and Outcomes Among US Medicaid Beneficiaries

Systemic lupus erythematosus (SLE) is a serious chronic autoimmune disease with substantial morbidity and mortality. Although improved diagnostics and therapeutics have contributed to declining mortality rates, important disparities exist in SLE survival rates by race, ethnicity, gender, age, country, and social disadvantage. This review highlights the burden of SLE and lupus nephritis among Medicaid beneficiaries, outlines barriers in access to high-quality SLE care and medication adherence in the Medicaid SLE population, and summarizes disparities in adverse outcomes among SLE patients enrolled in Medicaid.

Understanding the Role and Challenges of Patient Preferences in Disparities in Rheumatologic Disease Care

Evidence suggests patient preferences, including values and perspectives, have affected clinical outcomes, such as compliance, patient well-being, and satisfaction with care. A literature review was conducted with the purpose of exploring the tools used to elicit patients' treatment preferences and their roles in clinical outcomes. This review revealed racial differences in treatment preferences among patients with rheumatic and musculoskeletal diseases. The use of decision aids is a proactive intervention with potential for reducing race disparities and improving clinical outcomes. The utilization of patient preferences and values can improve outcomes by complementing the shared decision-making approach between patients and rheumatologists.

Health Disparities in Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease characterized by autoantibody production and diverse clinical manifestations. The many complex, overlapping, and closely associated factors that influence SLE susceptibility and outcomes include ethnic disparities, low adherence to medications, and poverty, and geography. Epigenetic mechanisms may provide the link between these environmental exposures and behaviors and the disproportionate burden of SLE seen in ethnic minorities. Attention to these modifiable social determinants of health would not only improve outcomes for vulnerable patients with SLE but likely reduce susceptibility to SLE as well through epigenetic changes.

Initial disease severity, cardiovascular events and all-cause mortality among patients with systemic lupus erythematosus

OBJECTIVE

SLE is associated with high risks of cardiovascular disease (CVD) and mortality, and has a wide spectrum of presentations. We investigated whether SLE severity at diagnosis was associated with CVD or mortality risk.

METHODS

Within Medicaid (2000-10), we identified patients 18-65 years of age with incident SLE. Initial SLE severity was classified-mild, moderate, or severe-during the baseline year prior to the start of follow-up (incident index date) using a published algorithm based on SLE-related medications and diagnoses. Patients were followed from the index date to the first CVD event or death, disenrollment, loss to follow-up or end of follow-up period. Cox and Fine-Gray regression models, adjusted for demographics and comorbidities accounting for the competing risk of death (for CVD), estimated CVD and mortality risks by baseline SLE severity.

RESULTS

Of 15 120 incident SLE patients, 48.7% had mild initial SLE severity, 33.9% moderate and 17.4% severe. Mean (s.d.) follow-up was 3.3 (2.4) years. After multivariable adjustment, CVD subdistribution hazard ratios (HRSD) were higher for initially severe [HRSD 1.64 (95% CI 1.32, 2.04)] and moderate [HRSD 1.19 (95% CI 1.00, 1.41)] SLE vs mild SLE. Mortality HRs were also higher for initially severe [HR 3.11 (95% CI 2.49, 3.89)] and moderate [HR 1.61 (95% CI 1.29, 2.01)] SLE vs mild SLE.

CONCLUSION

SLE patients with high initial severity had elevated mortality and CVD events risks compared with those who presented with milder disease. This has implications for clinical care and risk stratification of newly diagnosed SLE patients.

Single-nucleotide polymorphisms influence the promoter activities of systemic lupus erythematosus-associated genes

Systemic lupus erythematosus (SLE) is a protypical autoimmune disease and genetic factors play important roles in its pathogenesis. Since present SLE susceptibility loci are mainly studied through meta-analysis of genome-wide association study, we performed promoter activity analysis to examine the biological functions of SLE-associated single-nucleotide polymorphisms (SNPs). We found at SNP positions rs1341239, rs1800795, rs1800796, rs1800872, rs1800871, rs187238, rs360719, rs8178822, rs3761549, different alleles influenced respective promoter activities in different manners, and the effects also appeared under glucocorticoid treatment. In addition, some SNPs showed strong correlations with levels of respective serum factors, but in most cases the associations were only demonstrated in SLE individuals. Our study has further disclose the functional roles of SLE-associate SNPs in SLE pathogenesis.

Area-Level Predictors of Medication Nonadherence Among US Medicaid Beneficiaries With Lupus: A Multilevel Study

OBJECTIVE

Adherence to hydroxychloroquine (HCQ) treatment in patients with systemic lupus erythematous (SLE) is suboptimal. Although individual-level factors, including younger age and non-white race/ethnicity, have been implicated, contextual factors have not been explored. The aim of this study was to investigate the effect of contextual factors, including racial composition, socioeconomic status, and the concentration of health care resources, on adherence to HCQ among SLE patients enrolled in Medicaid.

METHODS

We identified SLE patients from 28 states in the US who enrolled in Medicaid (2000-2010) and in whom HCQ treatment was newly initiated (no use for ≥6 months). We required 12 months of continuous enrollment with complete drug dispensing data and measured adherence using the proportion of days covered (PDC). We identified individual-level variables from Medicaid, zip code-level, county-level and state-level sociodemographic variables from the American Community Survey, and health resources from Area Health Resources Files. We used 4-level hierarchical multivariable logistic regression models to examine the odds ratios (ORs) and 95% credible intervals (95% CrIs) of adherence (PDC ≥80%) versus nonadherence.

RESULTS

Among 10,268 patients with SLE in whom HCQ treatment was initiated, 15% were adherent to treatment. After we adjusted for individual-level characteristics, we observed lower odds of adherence among patients living in zip code areas with a higher percentage of black individuals (highest tertile OR 0.81 [95% CrI 0.69-0.96] versus lowest tertile). This association persisted after controlling for area-level educational attainment, percent below federal poverty level (FPL), urbanicity, and health care resources. We did not observe statistically significant associations with zip code-level percent Hispanic, percent white, education, or percent below FPL. The odds of adherence were higher in counties with more hospitals (OR 1.30 [95% CrI 1.07-1.58]).

CONCLUSION

Among Medicaid beneficiaries with SLE, we observed significant effects of racial composition and hospital concentration on HCQ adherence. Interventions that acknowledge and address contextual factors should be considered in order to reduce high rates of nonadherence in vulnerable populations.

Prevalence and incidence of systemic lupus erythematosus and associated outcomes in the 2009-2016 US Medicare population

OBJECTIVES

We aimed to update data on the prevalence and incidence of systemic lupus erythematosus (SLE) in the Medicare population and describe associated outcomes.

METHODS

This observational study used Medicare 20% random sample data 2007-2016 to estimate SLE prevalence and incidence 2009-2016. The study population included patients aged ≥18 years (stratified by <65 and ≥65 years) with Medicare fee-for-service coverage. The SLE definition was based on a published and validated algorithm. All-cause death, hospitalizations, and kidney disease incidence were defined for a prevalent SLE cohort 2011-2015. Unadjusted event rates during 5-year follow-up were reported per 100 patient-years.

RESULTS

The study included > 5 million eligible patients for each year 2009-2016. There were 19,518 (10,898, aged ≥65; 8620, aged <65) in 2016, extrapolated to 97,590 (54,490 aged ≥65; 43,100 aged <65) in the overall 2016 Medicare population. Age- and sex-adjusted prevalence rates (per 100,000 Medicare population) ranged from 301.1 in 2009 to 366.6 in 2016, all ages, and 184.0-239.9, ≥65 years. There were 2614 (1844 aged ≥65; 770 aged <65) incident patients in 2016; age-/sex-adjusted incidence rates (per 100,000 Medicare population) ranged from 46.9 in 2009 to 49.0 in 2016, all ages, and 37.5-40.8, ≥65. Five-year unadjusted mortality, elderly vs. younger, was 8.8 vs. 3.8, morbidity 34.5 vs. 32.4, and kidney disease incidence 19.8 vs. 18.0 per 100 patient-years.

CONCLUSIONS

Prevalence rates steadily increased while incidence was relatively stable 2009-2016. Our data should be interpreted with caution due to our elderly study population.

Inherited and Environmental Factors Influence Human Monocyte Heterogeneity

Blood monocytes develop in the bone marrow before being released into the peripheral circulation. The circulating monocyte pool is composed of multiple subsets, each with specialized functions. These cells are recruited to repopulate resident monocyte-derived cells in the periphery and also to sites of injury. Several extrinsic factors influence the function and quantity of monocytes in the blood. Here, we outline the impact of sex, ethnicity, age, sleep, diet, and exercise on monocyte subsets and their function, highlighting that steady state is not a single physiological condition. A clearer understanding of the relationship between these factors and the immune system may allow for improved therapeutic strategies.

Does SLE widen or narrow race/ethnic disparities in the risk of five co-morbid conditions? Evidence from a community-based outpatient care system

OBJECTIVE

The heterogeneous spectrum of systemic lupus erythematosus (SLE) often presents with secondary complications such as cardiovascular disease (CVD), infections and neoplasms. Our study assessed whether the presence of SLE independently increases or reduces the disparities, accounting for the already higher risk of these outcomes among racial/ethnic minority groups without SLE.

METHODS

We defined a cohort using electronic health records data (2005-2016) from a mixed-payer community-based outpatient setting in California serving patients of diverse racial/ethnic backgrounds. The eligible population included adult patients with SLE and matched non-SLE patients (≥18 years old). SLE was the primary exposure. The following outcomes were identified: pneumonia, other infections, CVD and neoplasms. For each racial/ethnic group, we calculated the proportion of incident co-morbidities by SLE exposure, followed by logistic regression for each outcome with SLE as the exposure. We evaluated interaction on the additive and multiplicative scales by calculating the relative excess risk due to interaction and estimating the cross-product term in each model.

RESULTS

We identified 1036 SLE cases and 8875 controls. The incidence for all outcomes was higher among the SLE exposed. We found little difference in the odds of the outcomes associated with SLE across racial/ethnic groups, even after multivariable adjustment. This finding was consistent on the multiplicative and additive scales.

CONCLUSION

We demonstrated that SLE status does not independently confer substantial interaction or heterogeneity by race/ethnicity toward the risk of pneumonia, other infections, CVD or neoplasms. Further studies in larger datasets are necessary to validate this novel finding.