Incidence and prevalence of systemic lupus erythematosus among Arab and Chaldean Americans in southeastern Michigan: the Michigan Lupus Epidemiology and Surveillance Program

Insights into systemic lupus erythematosus: a retrospective observational study of clinical features, autoantibodies, and gender-related differences

This study aims to analyze the clinical and immunologic features of SLE in Jordan, while also investigating the impact of age and gender on disease presentation. The study included 275 patients diagnosed with SLE. Data were collected through meticulous patient interviews and thorough examination of patient hospital records. The cohort exhibited a mean age of 36.8 ± 12.9 years, with an average disease duration of 7.0 ± 7.8 years. The mean age at diagnosis was 29.9 ± 12.1 years, and the female to male ratio was 7.8:1. The most frequently observed symptoms were arthralgia (90.2%), fatigue (80.7%), hematologic manifestations (62%), photosensitivity (60.7%), Raynaud's phenomenon (53.5%), and malar rash (50.9%). The frequencies of various autoantibodies were as follows: ANA (96.7%), anti-dsDNA (39.6%), anti-SSA/Ro (32.8%), anti-Sm (21.8%), anti-U1-RNP (20.6%), and anti-SSB/La (15.5%). Male patients tended to receive a diagnosis at a younger age and exhibited a higher likelihood of experiencing severe manifestations compared to females. Additionally, juvenile onset patients demonstrated an increased likelihood of fever, photosensitivity, myositis, and anti-dsDNA autoantibodies, while adult onset patients were more predisposed to having anti-Ro, anti-La, and RF autoantibodies. This study reveals that the most prevalent manifestations of SLE in the Jordanian cohort encompassed arthralgia, fatigue, and hematologic manifestations. The prevalence of alopecia and Raynaud's phenomenon exceeded that observed in other published cohorts, while arthritis and discoid rash were less frequently encountered. The study highlights that males are more susceptible to developing severe manifestations of SLE compared to females.

Cost-related prescription non-adherence and patient-reported outcomes in systemic lupus erythematosus: The Michigan Lupus Epidemiology & Surveillance program

OBJECTIVES

Medication access and adherence play key roles in determining patient outcomes. We investigated whether cost-related non-adherence (CRNA) to prescription medications was associated with worse patient-reported outcomes in a population-based systemic lupus erythematosus (SLE) cohort.

METHODS

Sociodemographic and prescription data were collected by structured interviews in 2014-2015 from patients meeting SLE criteria in the established Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We examined the associations between CRNA and potential confounders such as sociodemographics and health insurance coverage, and outcome measures of SLE activity and damage using multivariable linear regression.

RESULTS

462 SLE participants completed the study visit: 430 (93.1%) female, 208 (45%) Black, and mean age 53.3 years. 100 (21.6%) participants with SLE reported CRNA in the preceding 12 months. After adjusting for covariates, CRNA was associated with both higher levels of current SLE disease activity [SLAQ: β coeff 2.7 (95% CI 1.3, 4.1), p < 0.001] and damage [LDIQ β coeff 1.4 (95% CI 0.5, 2.4), p = 0.003]. Race, health insurance status, and fulfilling Fibromyalgia (FM) Survey Criteria were independently associated with both higher (worse) SLAQ and LDIQ scores; female sex was further associated with higher SLAQ scores.

CONCLUSION

Patients with SLE who reported CRNA in the previous 12 months had significantly worse self-reported current disease activity and damage scores compared to those not reporting CRNA. Raising awareness and addressing barriers or concerns related to financial implications and accessibility issues in care plans may help to improve these outcomes.

The Immunodiagnostic Utility of Antinuclear Antibody Patterns: A Prediction for Renal Involvement in Systemic Lupus Erythematosus Patients in the Western Region of Saudi Arabia

Objectives Previous studies have noted associations between the immunofluorescence patterns of antinuclear autoantibodies (ANA) and the autoimmune responses seen in systemic lupus erythematosus (SLE). In this study, the authors tested the hypothesis of whether ANA patterns predict renal involvement in SLE patients. Method A retrospective study was carried out on consecutive SLE patients who had ANA staining pattern data and who were screened for renal involvement defined as all-stage proteinuria or chronic kidney disease (CKD) at a referral tertiary center in western Saudi Arabia from December 2021 to February 2022. Demographic data and levels of lupus immune markers including ANA titers, anti-double-stranded deoxyribonucleic acid antibodies (anti-dsDNA), complements C3 and C4, anticardiolipin (aCL) immunoglobulin (Ig) G and IgM, anti-β2 glycoprotein (β2-IgM and β2-IgG), and lupus anticoagulant (LA) antibodies were collected. Result Among 243 patients included, 25.1% had renal involvement (95% confidence interval {CI}=19.8-31.0). A mixed ANA pattern was associated with a higher prevalence of renal involvement (46.2%), followed by homogenous (26.5%) and speckled (25.6%) patterns, compared with 4.5% for the other patterns (p=0.044). No further association of renal involvement was observed with other biological markers. Adjusted logistic regression showed age (odds ratio {OR}=0.95; 95% CI=0.92-0.97) and mixed ANA pattern (OR=26.66; 95% CI=2.53-281.11) to be independently associated with renal involvement, explaining 12.6% of the variance. Conclusion A mixed homogenous/speckled ANA staining pattern is associated with an increased risk of renal involvement, independent of ANA titer or other lupus immune markers. The potential clinical applications of the ANA staining pattern in SLE should be explored in various subtypes of SLE and patient groups.

Gender-Diverse Inclusion in Immunological Research: Benefits to Science and Health

The differences between male and female immune systems are an under-researched field, ripe for discovery. This is evidenced by the stark sex biases seen in autoimmunity and infectious disease. Both the sex hormones (oestrogen and testosterone), as well as the sex chromosomes have been demonstrated to impact immune responses, in multiple ways. Historical shortcomings in reporting basic and clinical scientific findings in a sex-disaggregated manner have led not only to limited discovery of disease aetiology, but to potential inaccuracies in the estimation of the effects of diseases or interventions on females and gender-diverse groups. Here we propose not only that research subjects should include both cis-gender men and cis-gender women, but also transgender and gender-diverse people alongside them. The known interaction between the hormonal milieu and the sex chromosomes is inseparable in cis-gender human research, without the confounders of puberty and age. By inclusion of those pursuing hormonal affirmation of their gender identity- the individual and interactive investigation of hormones and chromosomes is permitted. Not only does this allow for a fine-tuned dissection of these individual effects, but it allows for discovery that is both pertinent and relevant to a far wider portion of the population. There is an unmet need for detailed treatment follow-up of the transgender community- little is known of the potential benefits and risks of hormonal supplementation on the immune system, nor indeed on many other health and disease outcomes. Our research team has pioneered the inclusion of gender-diverse persons in our basic research in adolescent autoimmune rheumatic diseases. We review here the many avenues that remain unexplored, and suggest ways in which other groups and teams can broaden their horizons and invest in a future for medicine that is both fruitful and inclusive.

Systemic lupus erythematosus: overview, management and COVID-19

Systemic lupus erythematosus is a complex multi-system disease affecting various systems of the body. The aetiology remains unclear; however, it is thought that immune system dysregulation, environmental factors and viral susceptibility can trigger the disease. Mortality remains high due to cardiovascular disease, infection and lupus nephritis. Clinical assessment should comprise an extensive history, detailed physical examination and relevant laboratory tests. Management begins with an in-depth understanding of disease-specific complications and associated comorbidities. Treatments should be based on a shared decision-making process between the patient and the clinician. Review by a specialist nurse is vital for ongoing support and education. Current treatments can increase the risk of COVID-19 infection and disease severity, so caution is needed in the current climate. New treatments are emerging and offer hope to those with refractory disease.

Activity of Protein S-C4b Binding Protein and Total TFPI Levels in Egyptian SLE Patients: A Cross-Sectional Study

BACKGROUND: Systemic lupus erythematosus (SLE) is an immune disorder with alternating active and remission phases. Cardiovascular diseases and thrombosis are the major causes of mortality in SLE. The anticoagulant activity of Protein S (PS) is complemented by C4 binding protein (C4BP) and tissue factor pathway inhibitor (TFPI). AIM: This study aims to determine the extent of change in the levels of PS activity, C4BP, and total TFPI in active SLE in comparison to the SLE remission phase and their association with thrombosis during SLE flare. METHODS: The study included 180 Egyptian SLE patients who were classified into two groups: 100 SLE cases as the active group and 80 SLE cases as the remission group. The PS activity levels were processed on automated coagulation analyzers, whereas the C4BP and total TFPI levels were measured via enzyme-linked immunosorbent assay. RESULTS: The PS activity and C4BP levels were lower in the active SLE cases than in the remitted ones (p < 0.05). The levels of PS activity and C4BP were revealed to be independent predictors of SELENA-SLEDAI flare scores. In active SLE cases, the PS activity and C4BP levels were rated as excellent and fair classifiers of thrombotic risk in SLE flare, respectively. The total TFPI levels showed no association with SLE activity or its thrombotic consequences. CONCLUSIONS: The levels of PS activity and C4BP act as important biomarkers for SLE activity. Both can be implanted as predictive tools for thrombosis during activity.

Autoimmune Regulator Gene Polymorphisms in Egyptian Systemic Lupus Erythematosus Patients: Preliminary Results

Background

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease. The autoimmune regulator (AIRE) is a master regulator of self-tolerance development. AIRE mutations lead to the development of autoimmune polyglandular syndrome type 1 while AIRE polymorphisms have been linked to organ-specific autoimmunity. The study is aimed at addressing the association between AIRE polymorphisms, rs2075876 (G > A) and rs760426 (A > G), and SLE susceptibility and expression in Egyptian patients.

Methods

Ninety-nine patients were included. One hundred and ten, and 123 control subjects were genotyped for rs2075876 and rs760426, respectively. Lupus severity was assessed using the Lupus Severity of Disease Index and Lupus Severity Index (LSI). Systemic Lupus International Collaborating Clinics (SLICC)/American College of Rheumatology (ACR) damage index was considered. Genotyping was done using StepOne Real-Time PCR. Results. AIRE rs760426 GG was more frequent in the patients under the genotype level (14.1% vs. 4.9%, p = 0.032) and recessive model (14.1% vs. 4.9%, p = 0.017, OR = 3.2 (1.2-8.7)). Musculoskeletal involvement and nephritis were associated with AIRE rs2075876 under the dominant (97.9% vs. 80.8%, p = 0.009, OR = 11 (1.3-89.2)) and recessive models (100% vs. 69.3%, p = 0.032), respectively; and both were linked to AIRE rs2075876 at the allelic level: 98.3% vs. 85%, p = 0.005, OR = 10.1 (1.3-76.6) and 82.8% vs. 68.6, p = 0.041, OR = 2.2 (1-4.7), respectively. Patients with AIRE rs2075876 A alleles had a higher damage index ( 1 ± 1.3 vs. 0.6 ± 1.1, p = 0.045) while the LSI was greater in patients with AIRE rs2075876 (8.5 ± 0.5 vs. 7.8 ± 1.3, p = 0.002) and rs760426 (8.6 ± 11 vs. 7.8 ± 1.2, p = 0.031) under the recessive models. Conclusion. AIRE rs760426 could share in SLE susceptibility while AIRE rs2075876 could influence the disease expression and burden in Egyptian patients.

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.

Update on lupus epidemiology: advancing health disparities research through the study of minority populations

The current review focuses on recent population-based studies that have examined the burden of lupus, disease outcomes, and gaps in quality of care, with an emphasis in research addressing health disparities.

Biomarkers of Systemic Lupus Erythematosus and Systemic Sclerosis diseases activity in a sample of Egyptian patients :Soluble Intercellular Adhesion Molecule-1 and Soluble Interleukin-2 Receptor, Case Control Study

Systemic Lupus Erythematosus (SLE) and systemic sclerosis (SSc) are systemic inflammatory autoimmune disorders characterized by a large spectrum of clinical and laboratory features. The aim of the present study was to investigate the possible use of serum level of soluble intercellular adhesion molecule-1(sICAM-1) and soluble interleukin-2 receptor (sIL-2Ra) as biomarkers for monitoring of SLE and SSc disease activity. Moreover, it aimed to compare the specificity and sensitivity as well as cut-off value of both biomarkers in a sample of Egyptian patients. 50 SLE patients, 30 SSc patients and 60 age and sex matched healthy controls were enrolled in our study. sICAM-1and sIL-2Ra were measured in serum samples obtained from all participants. In addition to Erythosedimentation rate (ESR), complete blood count (CBC), Antineuclearantibodies (ANA) estimation, disease activity of both diseases were also assessed. sICAM-1and sIL-2Ra levels were higher in SLE and SSc patients versus control. Both parameters are correlated with each other as well as the activity parameters. A cut-off levels of 455.59 (ng/ml) &2525935 (pg/ml) in both SLE & SSs respectively was observed with the highest specificity and sensitivity. It could be concluded that sICAM-1 and sIL-2Ra are noninvasive biomarkers for SLE and SSc that could play a pathophysiologic role in development and progression of both diseases. Moreover, sICAM-1 and sIL-2Ra are correlated with the disease activity at cut-off values of 455.59 (ng/ml) & 2525935(pg/ml) respectively.

Changing epidemiology of immune-mediated inflammatory diseases in immigrants: A systematic review of population-based studies

BACKGROUND

Immune-mediated inflammatory diseases (IMIDs) are systemic diseases of multifactorial etiology that share aberrant immune responses as the common final pathway. With rising globalization, their incidence is increasing in developing countries and among immigrants. Our primary objective was to systematically review the epidemiology of IMIDs in immigrants and conduct a meta-analysis to estimate the risk of IMIDs in immigrant populations according to their origin and destination countries.

METHODS

We systematically searched five biomedical databases and reviewed population-based studies, from inception through August 2018, that reported incidence or prevalence data of inflammatory bowel disease (IBD), multiple sclerosis (MS), type 1 diabetes (T1D), systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), ankylosing spondylitis (AS) or psoriasis and psoriatic arthritis (PPA) among immigrants and the host population.

RESULTS

The incidence and prevalence of IMIDs among immigrants differ from host populations, and evolve over subsequent generations. The risk of IBD among immigrants approximates that in hosts, especially among South Asians, with ulcerative colitis incidence changing prior to Crohn's disease incidence. MS risk is highest in Iranian immigrants, T1D in African immigrants and SLE in African and Iraqi immigrants. Data on other IMIDs are sparse. Significant heterogeneity between the studies precluded meta-analysis.

CONCLUSION

Based on our systematic review, the epidemiology of IMIDs among immigrants varies according to native and host countries, immigrant generation, and IMID type. The rapid evolution suggests a role for non-genetic factors and gene-environment interactions. Future studies should focus on these pattern shifts, given implications of rising global burden of IMIDs and immigration.

Lupus: the new epidemic

Is systemic lupus erythematosus (SLE) is occurring more frequently now than in decades past? Despite improvements in the identification of patients with SLE, the development of new classification criteria, and the recognition of several biomarkers used alone or in combination, the diagnosis of SLE is still a challenge for clinicians, in particular early in the course of the disease, which makes the recognition of secular trends difficult to ascertain. Lacking a uniform definition of preclinical lupus or incomplete lupus, it is difficult to predict accurately which patients would go on to develop SLE. We will briefly review the classification criteria, early or preclinical SLE, the epidemiology of SLE, antinuclear antibodies-negative SLE, and biomarkers of the disease.

Differences in health behaviors and health outcomes among non-Hispanic Whites and Arab Americans in a population-based survey in California

Background

Few population-based studies of Arab American health behaviors and outcomes exist outside of Michigan. We aimed to provide prevalence estimates of health behaviors and outcomes for Arab Americans and compare them to non-Hispanic Whites in California.

Methods

We used data from the 2003–2016 California Health Interview Surveys. We determined Arab American ethnicity using an algorithm that considered place of birth of the respondent or parent and use of Arabic language at home. Survey-weighted frequencies, chi-squared statistics, and logistic regression analyses were used to compare Arab Americans and non-Hispanic Whites on socioeconomic indicators, health behaviors and health outcomes. Multivariable models were adjusted for age, education level, and insurance status.

Results

Arab Americans had higher prevalence of no insurance, living below the federal poverty level, and home ownership than non-Hispanic Whites despite high levels of education and low unemployment prevalence. Arab Americans had reduced odds of alcohol consumption (OR: 0.33, 95% CI: 0.24, 0.45), binge drinking (OR: 0.28, 95% CI: 0.19, 0.40), and suicidal ideation (OR: 0.41, 0.25, 0.66) when compared to non-Hispanic Whites in multivariable models. Arab Americans had decreased odds of hypertension (OR: 0.64, 95% CI: 0.50, 0.83) and increased odds of diabetes (OR: 2.03, 95% CI: 1.23, 3.34) when compared to non-Hispanic Whites in multivariable models.

Conclusions

Arab Americans in California participate in less risky health behaviors and have better health outcomes than non-Hispanic Whites, except with regards to diabetes. Future work aiming to understand the health of Arab Americans should allow for self-identification and less reliance on country of origin and language use at home for sample selection.

Disparities in functional disability among Arab Americans by nativity, immigrant arrival cohort, and country of birth

This study contributes to a growing literature that documents the importance of arrival cohort and country of birth for differentiating the health of U.S. immigrants. We use nationally-representative data from nine years of the American Community Survey (2008-2016) to examine if an immigrant health advantage exists among Arab Americans ages 40+ (n = 49,867) and test if differences among the foreign-born vary by arrival cohort (pre-1991, 1991-2000, and 2001+). Results from multivariate logistic regression models find that foreign-born Arab Americans have higher odds of physical and self-care disability, and this varies by immigrant arrival cohort. The post-2001 cohort had the highest odds of both disabilities, while the earlier two cohorts did not differ from the native-born after adjustments for covariates. Compositional differences in birthplace, particularly the large influx of immigrants from Iraq in the most recent cohort, explained these differences. Political instabilities globally have contributed to a growing number of U.S. immigrants with vulnerabilities that might be overlooked when arrival cohorts are not considered.

Update on the epidemiology, risk factors, and disease outcomes of systemic lupus erythematosus

Obtaining an updated view of the epidemiology, risk factors, and prognosis of systemic lupus erythematosus (SLE) is pivotal to our understanding of the disease burden. Recent community-based studies with comprehensive methodology provided more accurate disease occurrence estimates and suggested that SLE may be more frequent than previously thought. Gender, race, and socioeconomic status are important disease determinants, and there is increasing appreciation of the contribution of family history and environmental exposures in SLE susceptibility. Owing to its systemic nature, assessment of disease activity is challenging, also pertaining to efforts to improve trial endpoints for better discrimination between active drug and placebo. Notably, emerging evidence supports that remission or low disease activity states and prevention of flares are realistic targets in the management of SLE associated with improved prognosis. For the future, we anticipate that high-throughput analyses in patient cohorts will enhance the identification of robust biomarkers for diagnosis, risk stratification, and personalized treatment.

The Health of Arab Americans in the United States: An Updated Comprehensive Literature Review

Background: Arab Americans are a historically understudied minority group in the United States and their health needs and risks have been poorly documented. We aim to provide an updated comprehensive review of the literature on Arab American physical and mental health and provide suggestions for future work in this field.

Methods: A comprehensive review of the English language medical and public health literature published prior to 2017 identified through multiple database searches was conducted with search terms describing Arab Americans and health outcomes and behaviors. The literature was qualitatively summarized by health behavior (vaccination, tobacco use, drug and alcohol use, and physical activity), health outcome (diabetes, mental health, cardiovascular disease, cancer, women's, and child health), and populations at increased risk of poor health outcomes (adolescents and the elderly).

Results: The majority of studies identified exploring Arab American health have been published since 2009 with an increase in the number of longitudinal and intervention studies done with this population. The majority of research is being undertaken among individuals living in ethnic enclaves due to the lack of an ethnic or racial identifier that may help identify Arab Americans from population-based studies. Studies highlight the conflicting evidence in the prevalence of diabetes and cardiovascular disease based on study sample, an increased understanding of cancer incidence and barriers to identification, and an increased level of knowledge regarding mental health and sexual health needs in the population. Information on health behaviors has also increased, with a better understanding of physical activity, alcohol and drug use, and vaccination.

Conclusion: More research on Arab American health is needed to identify risks and needs of this marginalized population given the current social and political climate in the United States, especially with regard to acculturation status and immigrant generation status. We provide recommendations on approaches that may help improve our understanding of Arab American health.

Epidemiology of systemic lupus erythematosus: an update

PURPOSE OF REVIEW

Systemic lupus erythematosus (SLE) is the prototypical systemic autoimmune disease with a significant disease burden across the world among different ethnic, racial, and age groups. The pathophysiological understanding of SLE is constantly evolving and with it, the need for a better definition of the disease itself, for understanding the risk among the different affected populations, and for identifying the factors responsible for the damage accrual through the years.

RECENT FINDINGS

More accurate estimates of incidence and prevalence of SLE among different ethnicities and minority groups not only in the USA, but also in Europe, Middle East, and Asia have provided new insights into the disease burden around the world. Despite advances in treatment, mortality among SLE patients remains high with significant ethnic and geographic variations.

SUMMARY

Sex, race, and ethnicity significantly affect SLE incidence, prevalence, and mortality.

Neonatal and Obstetrical Outcomes of Pregnancies in Systemic Lupus Erythematosus

Objectives

Systemic lupus erythematous (SLE) is a chronic autoimmune disease that affects women primarily of childbearing age. The objective of this study was to determine the neonatal and maternal outcomes of pregnancies in SLE patients compared to pregnancies in healthy controls.

Methods

We conducted a retrospective cohort study in a tertiary care hospital in Oman between January 2007 and December 2013. We analyzed 147 pregnancies and compared 56 (38.0%) pregnancies in women with SLE with 91 (61.9%) pregnancies in healthy control women. Disease activity was determined using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI).

Results

The mean age of the cohort was 30.0±5.0 years ranging from 19 to 44 years old. Patients with SLE were treated with hydroxychloroquine (n = 41; 73.2%), prednisolone (n = 38; 67.8%), and azathioprine (n = 17; 30.3%). There was no disease activity in 39.2% (n = 22) of patients while 41.0% (n = 23), 12.5% (n = 7), and 7.1% (n = 4) had mild (SLEDAI 1-5), moderate (SLEDAI 6-10), and severe (SLEDAI ³ 11) disease activity, respectively, at onset of pregnancy. Pregnancies in patients with SLE were associated with higher abortions (42.8% vs. 15.3%; p < 0.001), gestational diabetes (28.3% vs. 10.2%; p = 0.004), polyhydramnios (7.1% vs. 0.0%; p = 0.020), previous preterm pregnancies (8.9% vs. 1.0%; p = 0.030), and intrauterine growth retardation (21.4% vs. 0.0%; p < 0.001) when compared to pregnancies in healthy control women. Furthermore, the neonates born to mothers with SLE were more likely to be preterm (28.5% vs. 1.0%; p < 0.001), have a low birth weight (< 2 500 g) (32.1% vs. 1.0%; p < 0.001), and were associated with stillbirth (7.1% vs. 0.0%; p = 0.010) when compared to neonates born to healthy control mothers.

Conclusions

Pregnancies in women with SLE were associated with higher neonatal and maternal complications. Therefore, pregnant women with SLE should have their pregnancy accurately planned, monitored, and managed according to a multidisciplinary treatment schedule.

The effect of ethnicity and genetic ancestry on the epidemiology, clinical features and outcome of systemic lupus erythematosus

In this in-depth review, we examine the worldwide epidemiology of SLE and summarize current knowledge on the influence of race/ethnicity on clinical manifestations, disease activity, damage accumulation and outcome in SLE. Susceptibility to SLE has a strong genetic component, and trans-ancestral genetic studies have revealed a substantial commonality of shared genetic risk variants across different genetic ancestries that predispose to the development of SLE. The highest increased risk of developing SLE is observed in black individuals (incidence 5- to 9-fold increased, prevalence 2- to 3-fold increased), with an increased risk also observed in South Asians, East Asians and other non-white groups, compared with white individuals. Black, East Asian, South Asian and Hispanic individuals with SLE tend to develop more severe disease with a greater number of manifestations and accumulate damage from lupus more rapidly. Increased genetic risk burden in these populations, associated with increased autoantibody reactivity in non-white individuals with SLE, may explain the more severe lupus phenotype. Even after taking into account socio-economic factors, race/ethnicity remains a key determinant of poor outcome, such as end-stage renal failure and mortality, in SLE. Community measures to expedite diagnosis through increased awareness in at-risk racial/ethnic populations and ethnically personalized treatment algorithms may help in future to improve long-term outcomes in SLE.

Epidemiology of systemic lupus erythematosus

INTRODUCTION

Systemic lupus erythematosus (SLE) is a disease distributed worldwide, which occurs in both genders, and across racial/ethnic and age groups; however, higher rates are observed in adults, in women and in non-Caucasians. Genetic, environmental, sociodemographic and methodological issues are responsible not only for these differences but for the variable course and outcome of the disease. Non-Caucasians have a more severe disease with a higher risk for early mortality and damage accrual. Males also have a more severe disease; however, a negative impact of male gender on lupus outcomes has not been firmly established. Childhood-onset is associated with a more severe disease; moreover, it is also associated with higher damage and diminished survival; finally, late-onset lupus is mild but it is associated with higher damage accrual and a diminished survival. Areas covered: In this review, we discuss the incidence and prevalence of SLE, the impact of age, gender and race/ethnicity in SLE and in the survival of those affected. Expert commentary: Age, gender and race/ethnicity impact disease expression in SLE patients; despite improvements in survival, mortality in SLE remains almost three times higher than in the general population.

Antinuclear antibody prevalence in a general pediatric cohort from Mexico City: discordance between immunofluorescence and multiplex assays

OBJECTIVE

To characterize antinuclear antibody (ANA) prevalence according to distinct assay methodologies in a pediatric cohort from Mexico City, and to further examine associations with age and sex.

METHODS

Serum ANA were measured by indirect immunofluorescence assay (IFA) and multiplex immunoassay in 114 children aged 9-17 years. IFA was considered positive at a cutoff titer of ≥1:80. Agreement between assay methods was assessed by kappa statistic. Sensitivity, specificity, and 95% confidence intervals (CIs) of the multiplex were computed with IFA as the reference standard.

RESULTS

Of the 114 children (mean age 14.7 [standard deviation 2.1] years; 54 [47%] female), 18 of 114 (15.8%) were ANA positive by IFA, and 11 of 114 (9.6%) by 11-antigen multiplex assay. ANA prevalence was higher in females compared with males by both of the methods (ratios 1.6-1.9 to 1). Agreement between tests was classified as slight by kappa (κ=0.177 [95% CI -0.051, 0.406]). The multiplex immunoassay had sensitivity of 22.2% (95% CI 6.4, 47.6) and specificity of 92.7% (95% CI 85.6, 97.0), and failed to capture 3 of 4 (75%) of the high-titer (≥1:1280) IFA-positives.

CONCLUSION

Up to 15% of children in this general population cohort were ANA positive, with a higher rate of positivity among females according to both assay methods. Substantial discordance in ANA results was found between IFA and multiplex methods, even for high-titer IFA positives. These findings underscore the need to sufficiently account for assay characteristics when interpreting ANA test results, and support IFA as the more appropriate assay for studies of subclinical autoimmunity.

Incidence and prevalence of systemic lupus erythematosus among the native Arab population in UAE

Background and objectives There is a paucity of information about the epidemiology of systemic lupus erythematosus (SLE) amongst Arabs. The objective of this study was to determine the incidence and prevalence of SLE among the native Arab population of United Arab Emirates (UAE). Methods Patients with SLE were identified from three sources: medical records of two local tertiary hospitals (four years; 2009 to 2012), laboratory requests for serum double stranded deoxyribonucleic acid and serum anti-nuclear antibody and confirmed histopathologic diagnosis of SLE (skin and kidney biopsy specimens). All the patients identified with SLE met the criteria of the American College of Rheumatology. Incidence and prevalence were calculated using the state records of the UAE native population as the denominator. The age-adjusted incidence was calculated by direct standardization using the World Health Organization world standard population 2000-2025. Results Sixteen new cases (13 females and three males) fulfilled the American College of Rheumatology SLE criteria. The mean (±SD) age at time of diagnosis was 28.6 ± 12.4 years. The crude incidence ratio (per 100,000 population) was 3.5, 1.1, 2.1 and 2.1 in years 2009, 2010, 2011, 2012, respectively. The age-standardized incidence per 100,000 population for the four years was 8.6 (95% confidence interval 4.2-15.9). The age-standardized prevalence of SLE among the native population according to the 2012 population consensus was 103/100,000 population (95% confidence interval 84.5-124.4). Conclusion The age-adjusted incidence and prevalence among UAE Arabs is higher than has been reported among most other Caucasian populations. Furthermore, the prevalence of SLE in UAE seems much higher than other similar Arab countries in the Gulf region.

Rheumatic autoimmune diseases in women and midlife health

Autoimmune diseases such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and systemic sclerosis (scleroderma) preferentially affect women, and are characterized by systemic inflammation leading to target organ dysfunction. The public health burden of autoimmune diseases, which collectively represent a leading cause of morbidity and mortality among women throughout adulthood, is substantial. While some features of these diseases have been observed to improve over the menopausal transition, such as disease flare rate in SLE and skin softening and thinning in scleroderma, others, such as swollen and tender joints and radiographically confirmed damage in RA may worsen. The general trends, however, are not consistent or conclusive for all disease-related manifestations. Of great importance is the recognition that comorbid diseases, including osteoporosis and accelerated cardiovascular disease, contribute excess morbidity and mortality that becomes increasingly apparent as women with autoimmune diseases undergo the menopausal transition.