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Somers EC, Goodrich JM, Wang L, Harlow SD, Marder W, Hassett AL, Zick SM, McCune WJ, Gordon C, Barbour KE, Helmick CG, Strickland FM. Associations between CD70 methylation of T cell DNA and age in adults with systemic lupus erythematosus and population controls: The Michigan Lupus Epidemiology & Surveillance (MILES) Program. J Autoimmun 2024; 142:103137. [PMID: 38064919 PMCID: PMC10957300 DOI: 10.1016/j.jaut.2023.103137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/18/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Environmental factors can influence epigenetic regulation, including DNA methylation, potentially contributing to systemic lupus erythematosus (SLE) development and progression. We compared methylation of the B cell costimulatory CD70 gene, in persons with lupus and controls, and characterized associations with age. RESULTS In 297 adults with SLE and 92 controls from the Michigan Lupus Epidemiology and Surveillance (MILES) Cohort, average CD70 methylation of CD4+ T cell DNA across 10 CpG sites based on pyrosequencing of the promoter region was higher for persons with SLE compared to controls, accounting for covariates [β = 2.3, p = 0.011]. Using Infinium MethylationEPIC array data at 18 CD70-annoted loci (CD4+ and CD8+ T cell DNA), sites within the promoter region tended to be hypomethylated in SLE, while those within the gene region were hypermethylated. In SLE but not controls, age was significantly associated with pyrosequencing-based CD70 methylation: for every year increase in age, methylation increased by 0.14 percentage points in SLE, accounting for covariates. Also within SLE, CD70 methylation approached a significantly higher level in Black persons compared to White persons (β = 1.8, p = 0.051). CONCLUSIONS We describe altered CD70 methylation patterns in T lymphocyte subsets in adults with SLE relative to controls, and report associations particular to SLE between methylation of this immune-relevant gene and both age and race, possibly a consequence of "weathering" or accelerated aging which may have implications for SLE pathogenesis and potential intervention strategies.
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Affiliation(s)
- Emily C Somers
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA; University of Michigan, Department of Environmental Health Sciences, Ann Arbor, MI, USA; University of Michigan, Department of Obstetrics & Gynecology, Ann Arbor, MI, USA.
| | - Jaclyn M Goodrich
- University of Michigan, Department of Environmental Health Sciences, Ann Arbor, MI, USA
| | - Lu Wang
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA
| | - Sioban D Harlow
- University of Michigan, Department of Epidemiology, Ann Arbor, MI, USA
| | - Wendy Marder
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA; University of Michigan, Department of Obstetrics & Gynecology, Ann Arbor, MI, USA
| | - Afton L Hassett
- University of Michigan, Department of Anesthesiology, Ann Arbor, MI, USA
| | - Suzanna M Zick
- University of Michigan, Department of Family Medicine, Ann Arbor, MI, USA
| | - W Joseph McCune
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
| | - Caroline Gordon
- University of Birmingham, Rheumatology Research Group, Institute of Inflammation and Ageing, Birmingham, UK
| | - Kamil E Barbour
- Centers for Disease Control and Prevention, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, USA
| | - Charles G Helmick
- Centers for Disease Control and Prevention, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, GA, USA
| | - Faith M Strickland
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI, USA
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Hood RB, Terrell ML, Mardovich S, Somers EC, Pearson M, Barton H, Tomlinson MS, Marder ME, Barr DB, Marcus M. Polybrominated biphenyls (PBBs) and prevalence of autoimmune disorders among members of the Michigan PBB registry. Environ Res 2023; 239:117312. [PMID: 37806482 PMCID: PMC10843028 DOI: 10.1016/j.envres.2023.117312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/15/2023] [Accepted: 10/04/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Polybrominated biphenyls (PBBs), a class of endocrine disrupting chemicals, were the main chemicals present in one of the largest industrial accidents in the United States. We investigated the association between serum PBB-153 levels and autoimmune disorders among members of the Michigan PBB Registry. METHODS Eight hundred and ninety-five members of the registry had both a serum PBB-153 measurement and had completed one or more questionnaires about autoimmune disorders. Autoimmune disorders were examined collectively and within specific organ systems. Sex-stratified unadjusted and adjusted log-binomial models were used to examine the association between tertiles of serum PBB-153 levels and autoimmune disorders. Models were adjusted by lifestage at exposure (in utero, childhood, adulthood), smoking history (never, past, current), and total serum lipid levels (continuous). We utilized cubic spline models to investigate non-linearity between serum PBB-153 levels and the prevalence of autoimmune disorders. RESULTS Approximately 12.9% and 20.7% of male and female participants reported having one or more autoimmune disorders, respectively. After adjustment for potential confounders, we observed no association between PBB-153 tertiles and the composite classification of 'any autoimmune disorder' in either sex. We observed some evidence for an association between serum PBB-153 levels and rheumatoid arthritis in males and females; however, this was not statistically significant in females. We also observed some evidence for an association between serum PBB-153 levels and neurological- and thyroid-related autoimmune disorders in females, but again this was not statistically significant. Additionally, we identified dose-response curves for serum PBB-153 levels and the prevalence of autoimmune disorders that differed by lifestage of exposure and sex. CONCLUSIONS We observed some evidence that increasing serum PBB-153 levels were associated with three specified autoimmune disorders. Studies focusing on these three autoimmune disorders and the potential non-linear trend differences by lifestage of exposure warrant further investigation.
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Affiliation(s)
- Robert B Hood
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA.
| | - Metrecia L Terrell
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sarah Mardovich
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Emily C Somers
- Departments of Internal Medicine, Environmental Health Sciences and Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Melanie Pearson
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Hillary Barton
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Martha Scott Tomlinson
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - M Elizabeth Marder
- Department of Environmental Toxicology, University of California, Davis, CA, USA
| | - Dana Boyd Barr
- Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Michele Marcus
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA; Gangarosa Department of Environmental Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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Minhas D, Marder W, Hassett AL, Zick SM, Gordon C, Harlow SD, Wang L, Barbour KE, Helmick CG, McCune WJ, Somers EC. Cost-related prescription non-adherence and patient-reported outcomes in systemic lupus erythematosus: The Michigan Lupus Epidemiology & Surveillance program. Lupus 2023; 32:1075-1083. [PMID: 37378450 PMCID: PMC10585710 DOI: 10.1177/09612033231186113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- Deeba Minhas
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Wendy Marder
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Afton L Hassett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Suzanna M Zick
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Sioban D Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Lu Wang
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - W Joseph McCune
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Emily C Somers
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, MI, USA
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Schreiber S, Whibley D, Somers EC. Schroth Physiotherapeutic Scoliosis-Specific Exercise (PSSE) Trials-Systematic Review of Methods and Recommendations for Future Research. Children (Basel) 2023; 10:954. [PMID: 37371186 DOI: 10.3390/children10060954] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
The Schroth method is a non-operative treatment for scoliosis and kyphosis, used standalone or as an adjunct to bracing. While supporting evidence for its effectiveness is emerging, methodologic standardization and rigor are equivocal. Thus, we aimed to systematically review methods of published Schroth physiotherapeutic scoliosis-specific exercise (PSSE) trials and provide guidance for future research. We searched six databases for randomized controlled trials (RCT) and non-randomized studies of interventions (NRSIs) investigating the effect of Schroth in children and adults with scoliosis or kyphosis. General characteristics, methodological approaches, treatment protocols, and outcomes reporting were analyzed. Risk of bias (RoB) was assessed using an adapted Cochrane RoB2 tool for RCTs and ROBINS-I for NRSI. Eligible studies (n = 7) were conducted in six countries and included patients with Scheuermann's kyphosis (n = 1) and adolescent idiopathic scoliosis (n = 6). Though all seven studies used the term Schroth to describe their interventions, the Schroth method was used in four of seven studies, of which only one used Schroth classification, three used Schroth therapists, and none prospectively registered the study protocol. Overall, methodological rigor was suboptimal, potentially invalidating evidence synthesis. Authors should follow minimum standards for reporting, including prospectively registering detailed protocols; using appropriate exercise labeling, Schroth classification and certified therapists; naming and describing exercises per classification; and providing therapy dosages, prescription methods, and adherence.
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Affiliation(s)
- Sanja Schreiber
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB T6G 2G4, Canada
- Curvy Spine-Specialized Scoliosis, Kyphosis and Other Spinal Disorders Centre, Edmonton, AB T6E 1W7, Canada
| | - Daniel Whibley
- Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI 48109, USA
| | - Emily C Somers
- Departments of Internal Medicine, Environmental Health Sciences and Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
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Kartsonaki C, Baillie JK, Barrio NG, Baruch J, Beane A, Blumberg L, Bozza F, Broadley T, Burrell A, Carson G, Citarella BW, Dagens A, Dankwa EA, Donnelly CA, Dunning J, Elotmani L, Escher M, Farshait N, Goffard JC, Gonçalves BP, Hall M, Hashmi M, Sim Lim Heng B, Ho A, Jassat W, Pedrera Jiménez M, Laouenan C, Lissauer S, Martin-Loeches I, Mentré F, Merson L, Morton B, Munblit D, Nekliudov NA, Nichol AD, Singh Oinam BC, Ong D, Panda PK, Petrovic M, Pritchard MG, Ramakrishnan N, Ramos GV, Roger C, Sandulescu O, Semple MG, Sharma P, Sigfrid L, Somers EC, Streinu-Cercel A, Taccone F, Vecham PK, Kumar Tirupakuzhi Vijayaraghavan B, Wei J, Wils EJ, Ci Wong X, Horby P, Rojek A, Olliaro PL. Characteristics and outcomes of an international cohort of 600 000 hospitalized patients with COVID-19. Int J Epidemiol 2023; 52:355-376. [PMID: 36850054 PMCID: PMC10114094 DOI: 10.1093/ije/dyad012] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 02/01/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND We describe demographic features, treatments and clinical outcomes in the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) COVID-19 cohort, one of the world's largest international, standardized data sets concerning hospitalized patients. METHODS The data set analysed includes COVID-19 patients hospitalized between January 2020 and January 2022 in 52 countries. We investigated how symptoms on admission, co-morbidities, risk factors and treatments varied by age, sex and other characteristics. We used Cox regression models to investigate associations between demographics, symptoms, co-morbidities and other factors with risk of death, admission to an intensive care unit (ICU) and invasive mechanical ventilation (IMV). RESULTS Data were available for 689 572 patients with laboratory-confirmed (91.1%) or clinically diagnosed (8.9%) SARS-CoV-2 infection from 52 countries. Age [adjusted hazard ratio per 10 years 1.49 (95% CI 1.48, 1.49)] and male sex [1.23 (1.21, 1.24)] were associated with a higher risk of death. Rates of admission to an ICU and use of IMV increased with age up to age 60 years then dropped. Symptoms, co-morbidities and treatments varied by age and had varied associations with clinical outcomes. The case-fatality ratio varied by country partly due to differences in the clinical characteristics of recruited patients and was on average 21.5%. CONCLUSIONS Age was the strongest determinant of risk of death, with a ∼30-fold difference between the oldest and youngest groups; each of the co-morbidities included was associated with up to an almost 2-fold increase in risk. Smoking and obesity were also associated with a higher risk of death. The size of our international database and the standardized data collection method make this study a comprehensive international description of COVID-19 clinical features. Our findings may inform strategies that involve prioritization of patients hospitalized with COVID-19 who have a higher risk of death.
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Affiliation(s)
- Christiana Kartsonaki
- Medical Research Council (MRC) Population Health Research Unit, Clinical Trials Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - J Kenneth Baillie
- Roslin Institute, University of Edinburgh, Edinburgh, UK
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Joaquín Baruch
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Lucille Blumberg
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Fernando Bozza
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation (INI-FIOCRUZ), Ministry of Health, and D'Or Institute of Research and Education (IDOR), Rio de Janeiro, São Paulo, Brazil
| | | | | | - Gail Carson
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Barbara Wanjiru Citarella
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andrew Dagens
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Christl A Donnelly
- Department of Statistics, University of Oxford, Oxford, UK
- MRC Centre for Global Infectious Disease Analysis, Abdul Latif Jameel Institute for Disease and Emergency Analytics and Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Jake Dunning
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Martina Escher
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Bronner P Gonçalves
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Matthew Hall
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Madiha Hashmi
- Critical Care Asia and Ziauddin University, Karachi, Pakistan
| | | | - Antonia Ho
- Medical Research Council-University of Glasgow Centre for Virus Research, Glasgow, UK Department of Infectious Diseases, Queen Elizabeth University Hospital, Glasgow, UK
| | - Waasila Jassat
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | | | - Cedric Laouenan
- Université de Paris, France, Infection, Antimicrobials, Modelling, Evolution (IAME), INSERM, Paris, France
| | | | | | - France Mentré
- Université de Paris, France, Infection, Antimicrobials, Modelling, Evolution (IAME), INSERM, Paris, France
| | - Laura Merson
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Infectious Diseases Data Observatory, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Ben Morton
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child’s Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
- Inflammation, Repair and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | | | - Alistair D Nichol
- Irish Critical Care Critical Clinical Trials Network, Dublin, Ireland
| | | | - David Ong
- Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands
| | | | | | - Mark G Pritchard
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Grazielle Viana Ramos
- National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation (INI-FIOCRUZ), Ministry of Health, and D'Or Institute of Research and Education (IDOR), Rio de Janeiro, São Paulo, Brazil
| | | | - Oana Sandulescu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- National Institute for Infectious Diseases ‘Prof. Dr. Matei Bals’, Bucharest, Romania
| | - Malcolm G Semple
- Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- UK Respiratory Medicine, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Pratima Sharma
- University of Michigan Schools of Medicine & Public Health, Ann Arbor, Michigan, USA
| | - Louise Sigfrid
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Emily C Somers
- University of Michigan Schools of Medicine & Public Health, Ann Arbor, Michigan, USA
| | | | - Fabio Taccone
- Cliniques Universitaires de Bruxelles (CUB) Hopital Erasme, Anderlecht, Belgium
| | | | | | - Jia Wei
- Big Data Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Xin Ci Wong
- National Institutes of Health (NIH), Ministry of Health, Shah Alam, Malaysia
| | - Peter Horby
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Amanda Rojek
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Royal Melbourne Hospital, Melbourne, Australia
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Piero L Olliaro
- International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) Global Support Centre, Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Izmirly PM, Ferucci ED, Somers EC, Wang L, Lim SS, Drenkard C, Dall'Era M, McCune WJ, Gordon C, Helmick C, Parton H. Incidence rates of systemic lupus erythematosus in the USA: estimates from a meta-analysis of the Centers for Disease Control and Prevention national lupus registries. Lupus Sci Med 2021; 8:8/1/e000614. [PMID: 34921094 PMCID: PMC8685969 DOI: 10.1136/lupus-2021-000614] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/25/2021] [Indexed: 11/12/2022]
Abstract
Objective To estimate the annual incidence rate of SLE in the USA. Methods A meta-analysis used sex/race/ethnicity-specific data spanning 2002–2009 from the Centers for Disease Control and Prevention network of four population-based state registries to estimate the incidence rates. SLE was defined as fulfilling the 1997 revised American College of Rheumatology classification criteria. Given heterogeneity across sites, a random effects model was employed. Applying sex/race/ethnicity-stratified rates, including data from the Indian Health Service registry, to the 2018 US Census population generated estimates of newly diagnosed SLE cases. Results The pooled incidence rate per 100 000 person-years was 5.1 (95% CI 4.6 to 5.6), higher in females than in males (8.7 vs 1.2), and highest among black females (15.9), followed by Asian/Pacific Islander (7.6), Hispanic (6.8) and white (5.7) females. Male incidence was highest in black males (2.4), followed by Hispanic (0.9), white (0.8) and Asian/Pacific Islander (0.4) males. The American Indian/Alaska Native population had the second highest race-specific SLE estimates for females (10.4 per 100 000) and highest for males (3.8 per 100 000). In 2018, an estimated 14 263 persons (95% CI 11 563 to 17 735) were newly diagnosed with SLE in the USA. Conclusions A network of population-based SLE registries provided estimates of SLE incidence rates and numbers diagnosed in the USA.
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Affiliation(s)
- Peter M Izmirly
- Department of Medicine, Division of Rheumatology, New York University Grossman School of Medicine, New York, New York, USA
| | - Elizabeth D Ferucci
- Department of Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, Anchorage, Alaska, USA
| | - Emily C Somers
- University of Michigan Schools of Medicine & Public Health, Ann Arbor, Michigan, USA
| | - Lu Wang
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - S Sam Lim
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA, USA
| | - Cristina Drenkard
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA, USA
| | - Maria Dall'Era
- University of California, San Francisco, California, USA
| | - W Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Charles Helmick
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Hilary Parton
- New York City Department of Health and Mental Hygiene, New York, New York, USA
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Somers EC, Eschenauer GA, Troost JP, Golob JL, Gandhi TN, Wang L, Zhou N, Petty LA, Baang JH, Dillman NO, Frame D, Gregg KS, Kaul DR, Nagel J, Patel TS, Zhou S, Lauring AS, Hanauer DA, Martin E, Sharma P, Fung CM, Pogue JM. Tocilizumab for Treatment of Mechanically Ventilated Patients With COVID-19. Clin Infect Dis 2021; 73:e445-e454. [PMID: 32651997 PMCID: PMC7454462 DOI: 10.1093/cid/ciaa954] [Citation(s) in RCA: 289] [Impact Index Per Article: 96.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/09/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Severe coronavirus disease 2019 (COVID-19) can manifest in rapid decompensation and respiratory failure with elevated inflammatory markers, consistent with cytokine release syndrome for which IL-6 blockade is an approved treatment. METHODS We assessed effectiveness and safety of IL-6 blockade with tocilizumab in a single-center cohort of patients with COVID-19 requiring mechanical ventilation. The primary endpoint was survival probability postintubation; secondary analyses included an ordinal illness severity scale integrating superinfections. Outcomes in patients who received tocilizumab compared with tocilizumab-untreated controls were evaluated using multivariable Cox regression with propensity score inverse probability of treatment weighting (IPTW). RESULTS 154 patients were included, of whom 78 received tocilizumab and 76 did not. Median follow-up was 47 days (range, 28-67). Baseline characteristics were similar between groups, although tocilizumab-treated patients were younger (mean: 55 vs 60 years), less likely to have chronic pulmonary disease (10% vs 28%), and had lower D-dimer values at time of intubation (median: 2.4 vs 6.5 mg/dL). In IPTW-adjusted models, tocilizumab was associated with a 45% reduction in hazard of death (HR, .55; 95% CI, .33-.90) and improved status on the ordinal outcome scale [OR per 1-level increase, .58; .36-.94). Although tocilizumab was associated with an increased proportion of patients with superinfections (54% vs 26%; P < .001), there was no difference in 28-day case fatality rate among tocilizumab-treated patients with versus without superinfection (22% vs 15%; P = .42). Staphylococcus aureus accounted for ~50% of bacterial pneumonia. CONCLUSIONS In this cohort of mechanically ventilated COVID-19 patients, tocilizumab was associated with lower mortality despite higher superinfection occurrence.
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Affiliation(s)
- Emily C Somers
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan, USA.,Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gregory A Eschenauer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan P Troost
- Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan L Golob
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Lu Wang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Nina Zhou
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ji Hoon Baang
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas O Dillman
- Department of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - David Frame
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin S Gregg
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Dan R Kaul
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jerod Nagel
- Department of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Shiwei Zhou
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Adam S Lauring
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - David A Hanauer
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily Martin
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher M Fung
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
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8
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Izmirly PM, Parton H, Wang L, McCune WJ, Lim SS, Drenkard C, Ferucci ED, Dall'Era M, Gordon C, Helmick CG, Somers EC. Prevalence of Systemic Lupus Erythematosus in the United States: Estimates From a Meta-Analysis of the Centers for Disease Control and Prevention National Lupus Registries. Arthritis Rheumatol 2021; 73:991-996. [PMID: 33474834 PMCID: PMC8169527 DOI: 10.1002/art.41632] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/23/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Epidemiologic data on systemic lupus erythematosus (SLE) are limited, particularly for racial/ethnic subpopulations in the US. This meta-analysis leveraged data from the Centers for Disease Control and Prevention (CDC) National Lupus Registry network of population-based SLE registries to estimate the overall prevalence of SLE in the US. METHODS The CDC National Lupus Registry network includes 4 registries from unique states and a fifth registry from the Indian Health Service. All registries defined cases of SLE according to the American College of Rheumatology (ACR) 1997 revised classification criteria for SLE. Case findings spanned either 2002-2004 or 2007-2009. Given the heterogeneity across sites, a random-effects model was used to calculate the pooled prevalence of SLE. An estimate of the number of SLE cases in the US was generated by applying sex/race-stratified estimates to the 2018 US Census population. RESULTS In total, 5,417 cases were identified as fulfilling the ACR SLE classification criteria. The pooled prevalence of SLE from the 4 state-specific registries was 72.8 per 100,000 person-years (95% confidence interval [95% CI] 65.3-81.0). The prevalence estimate was 9 times higher among females than among males (128.7 versus 14.6 per 100,000), and highest among Black females (230.9 per 100,000), followed by Hispanic females (120.7 per 100,000), White females (84.7 per 100,000), and Asian/Pacific Islander females (84.4 per 100,000). Among males, the prevalence of SLE was highest in Black males (26.7 per 100,000), followed by Hispanic males (18.0 per 100,000), Asian/Pacific Islander males (11.2 per 100,000), and White males (8.9 per 100,000). The American Indian/Alaska Native population had the highest race-specific SLE estimates, both among females (270.6 per 100,000) and among males (53.8 per 100,000). In 2018, an estimated 204,295 individuals (95% CI 160,902-261,725) in the US fulfilled the ACR classification criteria for SLE. CONCLUSION A coordinated network of population-based SLE registries provides more accurate estimates of the prevalence of SLE and the numbers of individuals affected with SLE in the US in 2018.
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Affiliation(s)
- Peter M. Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York, NY
| | - Hilary Parton
- New York City Department of Health and Mental Hygiene, Long Island City, New York, NY
| | - Lu Wang
- Department of Biostatistics, University of Michigan Schools of Medicine & Public Health, Ann Arbor, MI
| | - W. Joseph McCune
- Division of Rheumatology, Department of Medicine, University of Michigan Schools of Medicine, Ann Arbor, MI
| | - S. Sam Lim
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA
| | - Cristina Drenkard
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, GA
| | - Elizabeth D. Ferucci
- Division of Community Health Services, Department of Clinical and Research Services, Alaska Native Tribal Health Consortium, Anchorage, AK
| | - Maria Dall'Era
- Department of Medicine, University of California at San Francisco, San Francisco, CA
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Charles G. Helmick
- Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Emily C. Somers
- Division of Rheumatology, Department of Internal Medicine, Department of Environmental Health Sciences, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor MI
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9
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Daniels CJ, Rajpal S, Greenshields JT, Rosenthal GL, Chung EH, Terrin M, Jeudy J, Mattson SE, Law IH, Borchers J, Kovacs R, Kovan J, Rifat SF, Albrecht J, Bento AI, Albers L, Bernhardt D, Day C, Hecht S, Hipskind A, Mjaanes J, Olson D, Rooks YL, Somers EC, Tong MS, Wisinski J, Womack J, Esopenko C, Kratochvil CJ, Rink LD. Prevalence of Clinical and Subclinical Myocarditis in Competitive Athletes With Recent SARS-CoV-2 Infection: Results From the Big Ten COVID-19 Cardiac Registry. JAMA Cardiol 2021; 6:1078-1087. [PMID: 34042947 PMCID: PMC8160916 DOI: 10.1001/jamacardio.2021.2065] [Citation(s) in RCA: 195] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Question What is the prevalence of myocarditis in competitive athletes after COVID-19 infection, and how would different approaches to screening affect detection? Findings In this cohort study of 1597 US competitive collegiate athletes undergoing comprehensive cardiovascular testing, the prevalence of clinical myocarditis based on a symptom-based screening strategy was only 0.31%. Screening with cardiovascular magnetic resonance imaging increased the prevalence of clinical and subclinical myocarditis by a factor of 7.4 to 2.3%. Meaning These cardiac magnetic resonance imaging findings provide important data on the prevalence of clinical and subclinical myocarditis in college athletes recovering from symptomatic and asymptomatic COVID-19 infections. Importance Myocarditis is a leading cause of sudden death in competitive athletes. Myocardial inflammation is known to occur with SARS-CoV-2. Different screening approaches for detection of myocarditis have been reported. The Big Ten Conference requires comprehensive cardiac testing including cardiac magnetic resonance (CMR) imaging for all athletes with COVID-19, allowing comparison of screening approaches. Objective To determine the prevalence of myocarditis in athletes with COVID-19 and compare screening strategies for safe return to play. Design, Setting, and Participants Big Ten COVID-19 Cardiac Registry principal investigators were surveyed for aggregate observational data from March 1, 2020, through December 15, 2020, on athletes with COVID-19. For athletes with myocarditis, presence of cardiac symptoms and details of cardiac testing were recorded. Myocarditis was categorized as clinical or subclinical based on the presence of cardiac symptoms and CMR findings. Subclinical myocarditis classified as probable or possible myocarditis based on other testing abnormalities. Myocarditis prevalence across universities was determined. The utility of different screening strategies was evaluated. Exposures SARS-CoV-2 by polymerase chain reaction testing. Main Outcome and Measure Myocarditis via cardiovascular diagnostic testing. Results Representing 13 universities, cardiovascular testing was performed in 1597 athletes (964 men [60.4%]). Thirty-seven (including 27 men) were diagnosed with COVID-19 myocarditis (overall 2.3%; range per program, 0%-7.6%); 9 had clinical myocarditis and 28 had subclinical myocarditis. If cardiac testing was based on cardiac symptoms alone, only 5 athletes would have been detected (detected prevalence, 0.31%). Cardiac magnetic resonance imaging for all athletes yielded a 7.4-fold increase in detection of myocarditis (clinical and subclinical). Follow-up CMR imaging performed in 27 (73.0%) demonstrated resolution of T2 elevation in all (100%) and late gadolinium enhancement in 11 (40.7%). Conclusions and Relevance In this cohort study of 1597 US competitive athletes with CMR screening after COVID-19 infection, 37 athletes (2.3%) were diagnosed with clinical and subclinical myocarditis. Variability was observed in prevalence across universities, and testing protocols were closely tied to the detection of myocarditis. Variable ascertainment and unknown implications of CMR findings underscore the need for standardized timing and interpretation of cardiac testing. These unique CMR imaging data provide a more complete understanding of the prevalence of clinical and subclinical myocarditis in college athletes after COVID-19 infection. The role of CMR in routine screening for athletes safe return to play should be explored further.
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Affiliation(s)
- Curt J Daniels
- Division of Cardiology, Department of Internal Medicine, Ohio State University, Columbus
| | - Saurabh Rajpal
- Division of Cardiology, Department of Internal Medicine, Ohio State University, Columbus
| | | | | | | | | | - Jean Jeudy
- University of Maryland School of Medicine, Baltimore
| | | | - Ian H Law
- University of Iowa Stead Family Children's Hospital, Iowa City
| | | | | | | | | | | | - Ana I Bento
- School of Public Health, Indiana University, Bloomington
| | | | | | - Carly Day
- Purdue University, West Lafayette, Indiana
| | | | | | - Jeffrey Mjaanes
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | | | | | - Matthew S Tong
- Division of Cardiology, Department of Internal Medicine, Ohio State University, Columbus
| | | | - Jason Womack
- Robert Wood Johnson Medical School, Rutgers University, Newark, New Jersey
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10
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Goldstein CA, Rizvydeen M, Conroy DA, O'Brien LM, Gupta G, Somers EC, Sharma P, Golob JL, Troost JP, Burgess HJ. The prevalence and impact of pre-existing sleep disorder diagnoses and objective sleep parameters in patients hospitalized for COVID-19. J Clin Sleep Med 2021; 17:1039-1050. [PMID: 33560208 DOI: 10.5664/jcsm.9132] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea and other sleep disorders overlap with comorbidities associated with poor outcomes related to severe acute respiratory syndrome coronavirus 2 infection. However, the prevalence of obstructive sleep apnea among patients hospitalized for COVID-19 and relationship to outcomes is poorly characterized, and the relevance of other sleep disorders remains unknown. The objective of this study was to identify the prevalence of pre-existing sleep disorders and association with outcomes related to severe COVID-19 illness. METHODS Patients with severe acute respiratory syndrome coronavirus 2 infection admitted to the University of Michigan Hospital System were included. Electronic medical records were queried for sleep disorders diagnostic codes. Data were extracted from polysomnography and home sleep testing in a subgroup with previous diagnostic testing at our center. Logistic regression was used to examine the association of sleep disorders with mechanical ventilation requirement, treatment with vasopressors, and death and Cox proportional hazards regression for time to discharge. RESULTS Among n = 572 adult patients hospitalized for COVID-19, 113 (19.8%) patients had obstructive sleep apnea, 4 patients had central sleep apnea (0.7%), 5 had hypoventilation (0.9%), 63 had insomnia (11.0%), and 22 had restless legs syndrome or periodic limb movements disorder (3.9%). After adjusting for age, sex, body mass index, and race, no significant relationship was apparent between sleep disorders diagnoses or indices of sleep-disordered breathing severity and outcomes. CONCLUSIONS This is the first study to determine the prevalence of obstructive sleep apnea and other sleep disorders in a well-characterized cohort of patients hospitalized for COVID-19. Once hospitalized, a significant contribution of sleep disorders to outcomes was not identified. Therefore, future evaluations should focus on earlier outcomes, such as infection or clinical manifestations after exposure to severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Cathy A Goldstein
- Sleep Disorders Centers, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Muneer Rizvydeen
- Sleep and Circadian Research Laboratory, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Deirdre A Conroy
- Sleep and Circadian Research Laboratory, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Louise M O'Brien
- Sleep Disorders Centers, Department of Neurology, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.,Department of Oral and Maxillofacial Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gita Gupta
- Sleep Disorders Centers, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Emily C Somers
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.,Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan
| | - Pratima Sharma
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jonathan L Golob
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Helen J Burgess
- Sleep and Circadian Research Laboratory, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
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11
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Sharma P, Chen V, Fung CM, Troost JP, Patel VN, Combs M, Norman S, Garg P, Colvin M, Aaronson K, Sonnenday CJ, Golob JL, Somers EC, Doshi MM. COVID-19 Outcomes Among Solid Organ Transplant Recipients: A Case-control Study. Transplantation 2021; 105:128-137. [PMID: 32890139 PMCID: PMC7853506 DOI: 10.1097/tp.0000000000003447] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Solid organ transplant (SOT) recipients are considered to be "vulnerable" to COVID-19 infection due to immunosuppression. To date, there are no studies that compared the disease severity of COVID-19 in SOT recipients with nontransplant patients. METHODS In this case-control study, we compared the outcomes of COVID-19 between SOT recipients and their matched nontransplant controls. The cases were all adult SOT recipients (N = 41) from our academic health center who were diagnosed with COVID-19 between March 10, 2020 and May 15, 2020 using positive reverse transcriptase polymerase chain reaction for SARS-CoV2. The controls (N = 121) were matched on age (±5 y), race, and admission status (hospital or outpatient). The primary outcome was death and secondary outcomes were severe disease, intubation and renal replacement therapy (RRT). RESULTS Median age of SOT recipients (9 heart, 3 lung, 16 kidney, 8 liver, and 5 dual organ) was 60 y, 80% were male and 67% were Black. Severe disease adjusted risk of death was similar in both the groups (hazard ratio = 0.84 [0.32-2.20]). Severity of COVID-19 and intubation were similar, but the RRT use was higher in SOT (odds ratio = 5.32 [1.26, 22.42]) compared to non-SOT COVID-19 patients. Among SOT recipients, COVID-19-related treatment with hydroxychloroquine (HCQ) was associated with 10-fold higher hazard of death compared to without HCQ (hazard ratio = 10.62 [1.24-91.09]). CONCLUSIONS Although African Americans constituted one-tenth of all SOT in our center, they represented two-thirds of COVID-19 cases. Despite high RRT use in SOT recipients, the severe disease and short-term death were similar in both groups. HCQ for the treatment of COVID-19 among SOT recipients was associated with high mortality and therefore, its role as a treatment modality requires further scrutiny.
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Affiliation(s)
- Pratima Sharma
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Vincent Chen
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Christopher M. Fung
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Jonathan P. Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI 48109
| | - Vaiibhav N. Patel
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Michael Combs
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Silas Norman
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Puneet Garg
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Monica Colvin
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Keith Aaronson
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Christopher J. Sonnenday
- Department of Surgery, School of Public Health Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Jonathan L. Golob
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Emily C. Somers
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
- Environmental Health Sciences, School of Public Health Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Mona M. Doshi
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
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12
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Charoenwoodhipong P, Harlow SD, Marder W, Hassett AL, McCune WJ, Gordon C, Helmick CG, Barbour KE, Wang L, Mancuso P, Somers EC, Zick SM. Dietary Omega Polyunsaturated Fatty Acid Intake and Patient-Reported Outcomes in Systemic Lupus Erythematosus: The Michigan Lupus Epidemiology and Surveillance Program. Arthritis Care Res (Hoboken) 2020; 72:874-881. [PMID: 31074595 PMCID: PMC6842394 DOI: 10.1002/acr.23925] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 05/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To examine associations between dietary intake of omega-3 (n-3; generally antiinflammatory) and omega-6 (n-6; generally proinflammatory) fatty acids and patient-reported outcomes in systemic lupus erythematosus (SLE). METHODS This study was based on the population-based Michigan Lupus Epidemiology and Surveillance cohort. Estimates of n-3 and n-6 intake were derived from Diet History Questionnaire II items (past year with portion size version). Patient-reported outcomes included self-reported lupus activity (Systemic Lupus Activity Questionnaire [SLAQ]). Multivariable regression, adjusted for age, sex, race, and body mass index, was used to assess associations between absolute intake of n-3 and n-6, as well as the n-6:n-3 ratio, and patient-reported outcomes. RESULTS Among 456 SLE cases, 425 (93.2%) were female, 207 (45.4%) were African American, and the mean ± SD age was 52.9 ± 12.3 years. Controlling for potential confounders, the average SLAQ score was significantly higher by 0.3 points (95% confidence interval [95% CI] 0.1, 0.6; P = 0.013) with each unit increase of the n-6:n-3 ratio. Both lupus activity and Patient-Reported Outcomes Measurement Information System (PROMIS) sleep disturbance scores were lower with each 1-gram/1,000 kcal increase of n-3 fatty acids (SLAQ regression coefficient β = -0.8 [95% CI -1.6, 0.0]; P = 0.055; PROMIS sleep β = -1.1 [95% CI -2.0, -0.2]; P = 0.017). Higher n-3 intakes were nonsignificantly associated with lower levels of depressive symptoms and comorbid fibromyalgia, and with higher quality of life, whereas results for the n6:n3 ratio trended in the opposite direction. CONCLUSION This population-based study suggests that higher dietary intake of n-3 fatty acids and lower n-6:n-3 ratios are favorably associated with patient-reported outcomes in SLE, particularly self-reported lupus activity and sleep quality.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Lu Wang
- University of MichiganAnn Arbor
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13
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Minhas D, Marder W, Harlow S, Hassett AL, Zick SM, Gordon C, Barbour KE, Helmick CG, Wang L, Lee J, Padda A, McCune WJ, Somers EC. Access and cost-related non-adherence to prescription medications among lupus cases and controls: the Michigan Lupus Epidemiology & Surveillance (MILES) Program. Arthritis Care Res (Hoboken) 2020; 73:1561-1567. [PMID: 32741110 PMCID: PMC9219566 DOI: 10.1002/acr.24397] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Medication access and adherence are important determinants of health outcomes. We investigated factors associated with access and cost-related non-adherence to prescriptions in a population-based cohort of systemic lupus erythematosus (SLE) patients and controls. METHODS Detailed sociodemographic and prescription data were collected by structured interview in 2014-2015 from participants in the Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We compared access between cases and frequency-matched controls and examined associated factors in separate multivariable logistic regression models. RESULTS 654 participants (462 SLE cases, 192 controls) completed the baseline visit; 584 (89%) were female, 285 (44%) black, and mean age was 53 years. SLE cases and controls reported similar frequencies of being unable to access prescribed medications (12.1% vs 9.4%, respectively; p=NS). SLE patients were twice as likely as controls to report cost-related prescription non-adherence in the preceding 12 months to save money (21.7% vs 10.4%; p=0.001), but also more likely to ask their doctor for lower cost alternatives (23.8% vs 15.6%, p=0.02). Disparities were found in association with income, race and health insurance status, but main findings persisted after adjusting for these and other variables in multivariable models. CONCLUSION SLE patients were more likely than controls from the general population to report cost-related prescription non-adherence, including skipping doses, taking less medicine and delaying filling prescriptions, yet less than 1 in 4 patients asked providers for lower cost medications. Consideration of medication costs in patient decision-making could provide a meaningful avenue for improving access and adherence to medications.
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Affiliation(s)
- Deeba Minhas
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Wendy Marder
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Sioban Harlow
- Dept. of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Afton L Hassett
- Dept. of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Suzanna M Zick
- Dept. of Family Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Kamil E Barbour
- Centers for Disease Control and Prevention, Atlanta, United States
| | | | - Lu Wang
- University of Michigan, Department of Biostatistics, Ann Arbor, MI, USA
| | - Jiha Lee
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Amrita Padda
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - W Joseph McCune
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Emily C Somers
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA.,University of Michigan, Department of Environmental Health Sciences, Ann Arbor, MI, USA.,University of Michigan, Department of Obstetrics & Gynecology, Ann Arbor, MI, USA
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14
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Somers EC, Eschenauer GA, Troost JP, Golob JL, Gandhi TN, Wang L, Zhou N, Petty LA, Baang JH, Dillman NO, Frame D, Gregg KS, Kaul DR, Nagel J, Patel TS, Zhou S, Lauring AS, Hanauer DA, Martin E, Sharma P, Fung CM, Pogue JM. Tocilizumab for treatment of mechanically ventilated patients with COVID-19. medRxiv 2020. [PMID: 32577684 PMCID: PMC7302290 DOI: 10.1101/2020.05.29.20117358] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Severe COVID-19 can manifest in rapid decompensation and respiratory failure with elevated inflammatory markers. This presentation is consistent with cytokine release syndrome in chimeric antigen receptor T cell therapy, for which IL-6 blockade is approved treatment. Methods We assessed effectiveness and safety of IL-6 blockade with tocilizumab in a single-center cohort of patients with COVID-19 requiring mechanical ventilation. The primary endpoint was survival probability post-intubation; secondary analyses included an ordinal illness severity scale integrating superinfections. Outcomes in patients who received tocilizumab compared to tocilizumab-untreated controls were evaluated using multivariable Cox regression with propensity score inverse probability weighting (IPTW). Findings 154 patients were included, of whom 78 received tocilizumab and 76 did not. Median follow-up was 47 days (range 28-67). Baseline characteristics were similar between groups, although tocilizumab-treated patients were younger (mean 55 vs. 60 years), less likely to have chronic pulmonary disease (10% vs. 28%), and had lower D-dimer values at time of intubation (median 2.4 vs. 6.5 mg/dL). In IPTW-adjusted models, tocilizumab was associated with a 45% reduction in hazard of death [hazard ratio 0.55 (95% CI 0.33, 0.90)] and improved status on the ordinal outcome scale [odds ratio per 1-level increase: 0.59 (0.36, 0.95)]. Though tocilizumab was associated with an increased proportion of patients with superinfections (54% vs. 26%; p<0.001), there was no difference in 28-day case fatality rate among tocilizumab-treated patients with versus without superinfection [22% vs. 15%; p=0.42]. Interpretation In this cohort of mechanically ventilated COVID-19 patients, tocilizumab was associated with a decreased likelihood of death despite higher superinfection occurrence. Randomized controlled trials are urgently needed to confirm these findings.
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Affiliation(s)
- Emily C Somers
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA.,University of Michigan, Department of Environmental Health Sciences, Ann Arbor, MI USA.,University of Michigan, Department of Obstetrics & Gynecology, Ann Arbor, MI USA
| | - Gregory A Eschenauer
- University of Michigan, Department of Clinical Pharmacy, College of Pharmacy, Ann Arbor, MI USA
| | - Jonathan P Troost
- University of Michigan, Michigan Institute for Clinical & Health Research, Ann Arbor, MI USA
| | - Jonathan L Golob
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Tejal N Gandhi
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Lu Wang
- University of Michigan, Department of Biostatistics, Ann Arbor, MI USA
| | - Nina Zhou
- University of Michigan, Department of Biostatistics, Ann Arbor, MI USA
| | - Lindsay A Petty
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Ji Hoon Baang
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Nicholas O Dillman
- University of Michigan, Department of Pharmacy, Michigan Medicine, Ann Arbor, MI USA
| | - David Frame
- University of Michigan, Department of Clinical Pharmacy, College of Pharmacy, Ann Arbor, MI USA
| | - Kevin S Gregg
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Dan R Kaul
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Jerod Nagel
- University of Michigan, Department of Pharmacy, Michigan Medicine, Ann Arbor, MI USA
| | - Twisha S Patel
- University of Michigan, Department of Pharmacy, Michigan Medicine, Ann Arbor, MI USA
| | - Shiwei Zhou
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Adam S Lauring
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - David A Hanauer
- University of Michigan, Department of Learning Health Sciences, Ann Arbor, MI USA
| | - Emily Martin
- University of Michigan, Department of Epidemiology, Ann Arbor, MI USA
| | - Pratima Sharma
- University of Michigan, Department of Internal Medicine, Ann Arbor, MI USA
| | - Christopher M Fung
- University of Michigan, Department of Emergency Medicine, Ann Arbor, MI USA
| | - Jason M Pogue
- University of Michigan, Department of Clinical Pharmacy, College of Pharmacy, Ann Arbor, MI USA
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Marder W, Littlejohn EA, Somers EC. Corrigendum to "Pregnancy and autoimmune connective tissue diseaes" [Best Practice & Research Clinical Rheumatology 30 (2016) 63-80]. Best Pract Res Clin Rheumatol 2020; 34:101490. [PMID: 32249023 DOI: 10.1016/j.berh.2020.101490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Wendy Marder
- Departments of Internal Medicine and OB/GYN, University of Michigan Medical School, NCRC B14-G236, 2800 Plymouth Rd, Ann Arbor, MI, 48109-2800, USA.
| | - Emily A Littlejohn
- Department of Internal Medicine, University of Michigan Medical School, NCRC B300-304M, Ann Arbor, MI, 48109-2800, USA.
| | - Emily C Somers
- Departments of Internal Medicine, OB/GYN, and Environmental Health Sciences, University of Michigan, Schools of Medicine and Public Health, NCRC B14-G236, 2800 Plymouth Rd, Ann Arbor, MI, 48109-2800, USA.
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Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, Marder W, Guyatt G, Branch DW, Buyon J, Christopher-Stine L, Crow-Hercher R, Cush J, Druzin M, Kavanaugh A, Laskin CA, Plante L, Salmon J, Simard J, Somers EC, Steen V, Tedeschi SK, Vinet E, White CW, Yazdany J, Barbhaiya M, Bettendorf B, Eudy A, Jayatilleke A, Shah AA, Sullivan N, Tarter LL, Birru Talabi M, Turgunbaev M, Turner A, D'Anci KE. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken) 2020; 72:461-488. [PMID: 32090466 DOI: 10.1002/acr.24130] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/10/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To develop an evidence-based guideline on contraception, assisted reproductive technologies (ART), fertility preservation with gonadotoxic therapy, use of menopausal hormone replacement therapy (HRT), pregnancy assessment and management, and medication use in patients with rheumatic and musculoskeletal disease (RMD). METHODS We conducted a systematic review of evidence relating to contraception, ART, fertility preservation, HRT, pregnancy and lactation, and medication use in RMD populations, using Grading of Recommendations Assessment, Development and Evaluation methodology to rate the quality of evidence and a group consensus process to determine final recommendations and grade their strength (conditional or strong). Good practice statements were agreed upon when indirect evidence was sufficiently compelling that a formal vote was unnecessary. RESULTS This American College of Rheumatology guideline provides 12 ungraded good practice statements and 131 graded recommendations for reproductive health care in RMD patients. These recommendations are intended to guide care for all patients with RMD, except where indicated as being specific for patients with systemic lupus erythematosus, those positive for antiphospholipid antibody, and/or those positive for anti-Ro/SSA and/or anti-La/SSB antibodies. Recommendations and good practice statements support several guiding principles: use of safe and effective contraception to prevent unplanned pregnancy, pre-pregnancy counseling to encourage conception during periods of disease quiescence and while receiving pregnancy-compatible medications, and ongoing physician-patient discussion with obstetrics/gynecology collaboration for all reproductive health issues, given the overall low level of available evidence that relates specifically to RMD. CONCLUSION This guideline provides evidence-based recommendations developed and reviewed by panels of experts and RMD patients. Many recommendations are conditional, reflecting a lack of data or low-level data. We intend that this guideline be used to inform a shared decision-making process between patients and their physicians on issues related to reproductive health that incorporates patients' values, preferences, and comorbidities.
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Affiliation(s)
- Lisa R Sammaritano
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Michael D Lockshin
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | - Wendy Marder
- University of Michigan School of Medicine, Ann Arbor
| | | | | | - Jill Buyon
- New York University School of Medicine, New York, New York
| | | | | | - John Cush
- Baylor Research Institute, Dallas, Texas
| | | | | | | | - Lauren Plante
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jane Salmon
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | | | | | | | - Evelyne Vinet
- McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Medha Barbhaiya
- Weill Cornell Medicine, Hospital for Special Surgery, New York, New York
| | | | - Amanda Eudy
- Duke University Medical Center, Durham, North Carolina
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology, Atlanta, Georgia
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Sammaritano LR, Bermas BL, Chakravarty EE, Chambers C, Clowse MEB, Lockshin MD, Marder W, Guyatt G, Branch DW, Buyon J, Christopher‐Stine L, Crow‐Hercher R, Cush J, Druzin M, Kavanaugh A, Laskin CA, Plante L, Salmon J, Simard J, Somers EC, Steen V, Tedeschi SK, Vinet E, White CW, Yazdany J, Barbhaiya M, Bettendorf B, Eudy A, Jayatilleke A, Shah AA, Sullivan N, Tarter LL, Birru Talabi M, Turgunbaev M, Turner A, D'Anci KE. 2020 American College of Rheumatology Guideline for the Management of Reproductive Health in Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2020; 72:529-556. [DOI: 10.1002/art.41191] [Citation(s) in RCA: 180] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 12/10/2019] [Indexed: 12/12/2022]
Affiliation(s)
| | | | | | | | | | | | - Wendy Marder
- University of Michigan School of Medicine Ann Arbor
| | | | | | - Jill Buyon
- New York University School of Medicine New York New York
| | | | | | - John Cush
- Baylor Research Institute Dallas Texas
| | | | | | | | - Lauren Plante
- Drexel University College of Medicine Philadelphia Pennsylvania
| | - Jane Salmon
- Weill Cornell MedicineHospital for Special Surgery New York New York
| | | | | | | | | | - Evelyne Vinet
- McGill University Health Center Montreal Quebec Canada
| | | | | | - Medha Barbhaiya
- Weill Cornell MedicineHospital for Special Surgery New York New York
| | | | - Amanda Eudy
- Duke University Medical Center Durham North Carolina
| | | | | | | | | | | | | | - Amy Turner
- American College of Rheumatology Atlanta Georgia
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Abstract
Autoimmune diseases (AID) are more prevalent in women than in men, and pregnancy-related factors such as hormonal modulation and fetal microchimerism may influence the future risk of maternal AID. For women with AID, optimizing reproductive health requires a continuum of multidisciplinary care that initiates well before the desire for pregnancy is articulated. Family planning is essential so that pregnancy can be timed when disease is stable and to allow for appropriate medication adjustments. When contraception is used, the choice of method needs to take into consideration underlying disease and laboratory features. For females undergoing gonadotoxic therapy, options for preserving ovarian health and fertility warrant consideration, even among those who are not contemplating future pregnancy. Both maternal and fetal outcomes are optimized with multispecialty care as well as close monitoring during pregnancy and the postpartum period and when treatment regimens compatible with pregnancy are maintained to control underlying disease activity.
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Affiliation(s)
- Emily C Somers
- University of Michigan Schools of Medicine & Public Health, Departments of Internal Medicine, Environmental Health Sciences and Obstetrics and Gynecology, 2800 Plymouth Rd, NCRC B14-G236, Ann Arbor, MI 48109-2800, USA.
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Somers EC, Lee J, Hassett AL, Zick SM, Harlow SD, Helmick CG, Barbour KE, Gordon C, Brummett CM, Minhas D, Padda A, Wang L, McCune WJ, Marder W. Prescription Opioid Use in Patients With and Without Systemic Lupus Erythematosus - Michigan Lupus Epidemiology and Surveillance Program, 2014-2015. MMWR Morb Mortal Wkly Rep 2019; 68:819-824. [PMID: 31557148 PMCID: PMC6762189 DOI: 10.15585/mmwr.mm6838a2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Littlejohn E, Marder W, Lewis E, Francis S, Jackish J, McCune WJ, Somers EC. The ratio of erythrocyte sedimentation rate to C-reactive protein is useful in distinguishing infection from flare in systemic lupus erythematosus patients presenting with fever. Lupus 2018; 27:1123-1129. [PMID: 29546774 DOI: 10.1177/0961203318763732] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Both C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) can be elevated in systemic lupus erythematosus (SLE) flare and infection, and are therefore of limited utility for distinguishing between the two conditions in febrile SLE patients. Methods A medical records review of hospitalizations (1997-2006) of SLE patients in the Michigan Lupus Cohort was performed. Eligible hospitalizations were those in which patients presented with a temperature of >100.3°F or with subjective fevers as a presenting complaint at admission. Detailed demographic, clinical, and laboratory data were collected. Multivariable logistic regression was used to examine the associations between ESR and CRP and the outcome of flare vs infection, adjusted for confounders. Results Among 557 SLE patients screened, there were 53 eligible hospitalizations (28 flares and 25 infections). Each unit increase in the ratio of ESR:CRP was associated with a 17% increase in the odds of fever being attributable to SLE flare compared to infection (OR 1.17, 95% CI 1.04, 1.31; p = 0.009), when adjusted for white blood cell count, SLE duration, sex, race, and age. ESR and CRP were not individually associated with flare vs infection when modeled with their ratio. Conclusions The ratio of ESR:CRP may provide diagnostic value beyond individual ESR and CRP levels in distinguishing flare vs infection in SLE patients presenting with fever.
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Affiliation(s)
- E Littlejohn
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA
| | - W Marder
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,2 Department of Obstetrics & Gynecology, 1259 University of Michigan , Ann Arbor, MI, USA
| | - E Lewis
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA
| | - S Francis
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,3 Orthopedics & Sports Medicine P.C., New Windsor, NY, USA
| | - J Jackish
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,4 25214 Park Nicollet/Health Partners Methodist Hospital , St. Louis Park, MN, USA
| | - W J McCune
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA
| | - E C Somers
- 1 Division of Rheumatology, Department of Internal Medicine, 1259 University of Michigan , Ann Arbor, MI, USA.,2 Department of Obstetrics & Gynecology, 1259 University of Michigan , Ann Arbor, MI, USA.,5 Department of Environmental Health Sciences, 1259 University of Michigan , Ann Arbor, MI, USA
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Abstract
Infertility and subfertility, menstrual irregularities, and decreased parity may occur in women with autoimmune diseases due to multiple factors, including underlying inflammatory disease, gonadotoxic medications, and psychosocial issues related to living with chronic disease. Awareness of these factors, as well as validation and support of patients confronting reproductive challenges, is important for providing comprehensive care to these women. An understanding of the expanding options for fertility preservation strategies during gonadotoxic medications is essential. Referral to a reproductive endocrinology clinic is indicated in this patient population.
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Affiliation(s)
- Emily C Somers
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA; Department of Obstetrics and Gynecology, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA; Department of Environmental Health Sciences, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - Wendy Marder
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA; Department of Obstetrics and Gynecology, University of Michigan, North Campus Research Complex, B014 G236, 2800 Plymouth Road, SPC 2800, Ann Arbor, MI 48109-2800, USA.
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Somers EC, Monrad SU, Warren JS, Solano M, Schnaas L, Hernandez-Avila M, Tellez-Rojo MM, Hu H. Antinuclear antibody prevalence in a general pediatric cohort from Mexico City: discordance between immunofluorescence and multiplex assays. Clin Epidemiol 2016; 9:1-8. [PMID: 28053555 PMCID: PMC5192054 DOI: 10.2147/clep.s121632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Emily C Somers
- Divison of Rheumatology, Department of Internal Medicine; Department of Environmental Health Sciences; Department of Obstetrics & Gynecology
| | | | - Jeffrey S Warren
- Division of Clinical Pathology, Department of Pathology, University of Michigan, Ann Arbor, MI, USA
| | - Maritsa Solano
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos
| | - Lourdes Schnaas
- Department of Developmental Neurobiology, National Institute of Perinatology, Mexico City, Mexico
| | - Mauricio Hernandez-Avila
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos
| | - Martha Maria Tellez-Rojo
- Center for Nutrition and Health Research, National Institute of Public Health, Cuernavaca, Morelos
| | - Howard Hu
- Occupational and Environmental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Ray D, Harlow S, Strickland F, Orlowski R, Marder W, McCune WJ, Somers EC. CD70 methylation of a regulatory region increases with age in lupus patients. The Journal of Immunology 2016. [DOI: 10.4049/jimmunol.196.supp.187.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Abstract
T cell DNA hypomethylation contributes to systemic lupus erythematosus (SLE), although the mechanisms are poorly understood. Previous work has shown that CD70, a B cell costimulatory ligand, is hypomethylated and overexpressed in lupus T cells, and that the overexpression leads to increased B cell costimulation and concomitant immunoglobulin overproduction. Recent evidence suggests that the methylation status of certain genes may characterize ‘epigenetic aging’, and that epigenetic age may be a stronger predictor than chronological age of health outcomes. CD70 has not been examined in this context, therefore we sought to characterize the methylation status of CD70 in lupus patients across age. CD4+ T cells were obtained from peripheral blood of 89 consecutive lupus patients enrolled in a population-based cohort. CD70 methylation of a regulatory region was assessed by bisulfite conversion and pyrosequencing. Mean methylation across 10 sites known to be hypomethylated in lupus patients was measured and correlated with age. CD70 methylation increased linearly with increasing age of lupus patients. These results suggest that CD70 may be involved in “epigenetic aging”, and that the increased hypomethylation of CD70 in younger patients may contribute to the earlier onset and increased severity of disease. Further studies of aging effects on methylation of immune genes involved in lupus may improve our understanding of the variability in susceptibility and onset of the disease.
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Marder W, Knight JS, Kaplan MJ, Somers EC, Zhang X, O'Dell AA, Padmanabhan V, Lieberman RW. Placental histology and neutrophil extracellular traps in lupus and pre-eclampsia pregnancies. Lupus Sci Med 2016; 3:e000134. [PMID: 27158525 PMCID: PMC4854113 DOI: 10.1136/lupus-2015-000134] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 03/18/2016] [Accepted: 03/28/2016] [Indexed: 12/12/2022]
Abstract
Objective Systemic lupus erythematosus (SLE) is associated with increased risk of adverse pregnancy outcomes, including pre-eclampsia, particularly in association with antiphospholipid antibody syndrome (APS). While significant placental abnormalities are expected in pre-eclampsia, less is known about how lupus activity and APS in pregnancy affect the placenta. We describe placental pathology from a population of lupus pregnancies, several of which were complicated by APS-related thromboses, in which pre-eclampsia and other complications developed. We performed standard histopathological placental review and quantified neutrophils and neutrophil extracellular traps (NETs) in the intervillous space, given the recognised association of NETs with lupus, APS and pre-eclampsia. Methods Pre-eclampsia, SLE and control placentas were scored for histological features, and neutrophils were quantified on H&E and immunohistochemical staining for the granular protein myeloperoxidase. NETs were identified by extracellular myeloperoxidase staining in the setting of decondensed nuclei. Non-parametric analysis was used to evaluate differences in netting and intact neutrophils between groups, with Kruskal–Wallis testing for associations between histological findings and neutrophils. Results Placentas were evaluated from 35 pregnancies: 10 controls, 11 pre-eclampsia, 4 SLE+pre-eclampsia and 10 SLE, including one complicated by catastrophic APS and one complicated by hepatic and splenic vein thromboses during pregnancy. Intrauterine growth restriction and oligohydramnios were observed in lupus cases but not controls. Significantly more NETs were found infiltrating placental intervillous spaces in pre-eclampsia, SLE+pre-eclampsia and all 10 SLE non-pre-eclampsia cases. The ratio of NETs to total neutrophils was significantly increased in all case groups compared with controls. When present, NETs were associated with maternal vasculitis, laminar decidual necrosis, maternal–fetal interface haemorrhage and non-occlusive fetal thrombotic vasculopathy. Conclusions In this pilot study of placental tissue from lupus pregnancies, outcomes were more complicated, particularly if associated with APS. Placental tissue revealed marked inflammatory and vascular changes that were essentially indistinguishable from placental tissue of pre-eclampsia pregnancies.
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Affiliation(s)
- Wendy Marder
- Division of Rheumatology, Department of Internal Medicine,University of Michigan, Ann Arbor, Michigan, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan , USA
| | - Mariana J Kaplan
- Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health , Bethesda, Maryland , USA
| | - Emily C Somers
- Division of Rheumatology, Department of Internal Medicine,University of Michigan, Ann Arbor, Michigan, USA; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA; Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Xu Zhang
- Division of Rheumatology, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan , USA
| | - Alexander A O'Dell
- Division of Rheumatology, Department of Internal Medicine, University of Michigan , Ann Arbor, Michigan , USA
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard W Lieberman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA; Department of Pathology, University of Michigan, Ann Arbor, Michigan, USA
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Berman D, Clinton C, Limb R, Somers EC, Romero V, Mozurkewich E. Prenatal Omega-3 Supplementation and Eczema Risk among Offspring at Age 36 Months. ACTA ACUST UNITED AC 2016. [PMID: 28649675 DOI: 10.21767/2471-304x.100014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Long-term follow-up was completed in 84 mother-infant pairs of 118 women who completed a randomized controlled trial of prenatal supplementation with EPA- or DHA-rich fish oil or soy oil placebo. The goal of this study was to determine whether prenatal omega-3 fatty acid supplementation protects offspring against development of early childhood allergies. METHODS AND FINDINGS Assessment of childhood allergic/atopic disease among offspring at age 36 months was performed by maternal interview using the National Health Interview Survey (NHIS) questions for childhood digestive allergies, wheezing, eczema or skin allergy, and respiratory allergy. Multiple logistic regressions examined the association between prenatal supplementation and childhood outcomes, adjusted for covariates. Eczema was reported in 26/84 (31%) of offspring at age 36 months, and was significantly more prevalent in the omega-3 supplementation groups vs. placebo: EPA 13/31 (41.9%); DHA 10/26 (38.5%); placebo 3/27 (11.1%), p=0.019. Compared to placebo, EPA and DHA were associated with ≥5 times risk of offspring eczema [odds ratios (ORs): EPA 5.8 (95% CI 1.4-23.3); DHA 5.0 (95% CI 1.2-21.0)]. After adjusting for other potential risk factors (race, birth weight, vaginal/Cesarean delivery, and maternal eczema) the magnitudes of association for omega-3 supplementation increased: EPA OR 8.1 (95% CI 1.4-45.6); DHA OR 9.6 (95% CI 1.6-58.5). Maternal eczema was also significantly associated with offspring eczema in the adjusted model: OR 10.8 (95% CI 2.1-54.3). CONCLUSION Contrary to our hypothesis, acids supplementation compared to soy oil was associated with a substantial increase in risk of childhood eczema. This association was not observed on childhood respiratory or digestive outcomes. It is unclear if these findings were driven by unfavorable effects of omega-3s, or whether there may have been unanticipated protective effects of the soy-based placebo with regards to eczema.
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Affiliation(s)
- D Berman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - C Clinton
- Department of Obstetrics and Gynecology, Cornell University, New York NY, United States
| | - R Limb
- University of Michigan, Ann Arbor, MI, United States
| | - E C Somers
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Department of Environmental Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - V Romero
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Michigan State University, College of Human Medicine, Grand Rapids, MI, United States
| | - E Mozurkewich
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of New Mexico, Albuquerque, NM, United States
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Abstract
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.
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Affiliation(s)
- Wendy Marder
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI USA
| | - Évelyne Vinet
- Division of Rheumatology, McGill University Health Centre, Montreal, Canada
- Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Canada
| | - Emily C. Somers
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI USA
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI USA
- Department of Environmental Health Sciences, University of Michigan, 2800 Plymouth Rd, NCRC B14-G236, Ann Arbor, MI 48109-2800 USA
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Somers EC, Ganser MA, Warren JS, Basu N, Wang L, Zick SM, Park SK. Mercury Exposure and Antinuclear Antibodies among Females of Reproductive Age in the United States: NHANES. Environ Health Perspect 2015; 123:792-8. [PMID: 25665152 PMCID: PMC4529012 DOI: 10.1289/ehp.1408751] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 02/04/2015] [Indexed: 05/03/2023]
Abstract
BACKGROUND Immune dysregulation associated with mercury has been suggested, although data in the general population are lacking. Chronic exposure to low levels of methylmercury (organic) and inorganic mercury is common, such as through fish consumption and dental amalgams. OBJECTIVE We examined associations between mercury biomarkers and antinuclear antibody (ANA) positivity and titer strength. METHODS Among females 16-49 years of age (n = 1,352) from the National Health and Nutrition Examination Survey (NHANES) 1999-2004, we examined cross-sectional associations between mercury and ANAs (indirect immunofluorescence; cutoff ≥ 1:80). Three biomarkers of mercury exposure were used: hair (available 1999-2000) and total blood (1999-2004) predominantly represented methylmercury, and urine (1999-2002) represented inorganic mercury. Survey statistics were used. Multivariable modeling adjusted for several covariates, including age and omega-3 fatty acids. RESULTS Sixteen percent of females were ANA positive; 96% of ANA positives had a nuclear speckled staining pattern. Geometric mean (geometric SD) mercury concentrations were 0.22 (0.03) ppm in hair, 0.92 (0.05) μg/L blood, and 0.62 (0.04) μg/L urine. Hair and blood, but not urinary, mercury were associated with ANA positivity (sample sizes 452, 1,352, and 804, respectively), after adjusting for confounders: for hair, odds ratio (OR) = 4.10 (95% CI: 1.66, 10.13); for blood, OR = 2.32 (95% CI: 1.07, 5.03) comparing highest versus lowest quantiles. Magnitudes of association were strongest for high-titer (≥ 1:1,280) ANA: hair, OR = 11.41 (95% CI: 1.60, 81.23); blood, OR = 5.93 (95% CI: 1.57, 22.47). CONCLUSIONS Methylmercury, at low levels generally considered safe, was associated with subclinical autoimmunity among reproductive-age females. Autoantibodies may predate clinical disease by years; thus, methylmercury exposure may be relevant to future autoimmune disease risk.
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Affiliation(s)
- Emily C Somers
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Housey M, DeGuire P, Lyon-Callo S, Wang L, Marder W, McCune WJ, Helmick CG, Gordon C, Dhar JP, Leisen J, Somers EC. Incidence and prevalence of systemic lupus erythematosus among Arab and Chaldean Americans in southeastern Michigan: the Michigan Lupus Epidemiology and Surveillance Program. Am J Public Health 2015; 105:e74-9. [PMID: 25790387 DOI: 10.2105/ajph.2014.302423] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the burden of systemic lupus erythematosus (SLE) among Arab and Chaldean Americans residing in southeast Michigan. METHODS For those meeting SLE criteria from the Michigan Lupus Epidemiology and Surveillance Registry, we determined Arab or Chaldean ethnicity by links with demographic data from birth certificates and with a database of Arab and Chaldean names. We compared prevalence and incidence of SLE for Arab and Chaldean Americans with estimates for non-Arab and non-Chaldean American Whites and Blacks. RESULTS We classified 54 individuals with SLE as Arab and Chaldean Americans. The age-adjusted incidence and prevalence estimates for Arab and Chaldean Americans were 7.6 and 62.6 per 100 000, respectively. Arab and Chaldean Americans had a 2.1-fold excess SLE incidence compared with non-Arab and non-Chaldean American Whites. Arab and Chaldean American women had both significantly higher incidence rates (5.0-fold increase) and prevalence estimates (7.4-fold increase) than did Arab and Chaldean American men. CONCLUSIONS Recognizing that Arab and Chaldean Americans experience different disease burdens from Whites is a first step toward earlier diagnosis and designing targeted interventions. Better methods of assigning ethnicity would improve research in this population.
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Affiliation(s)
- Michelle Housey
- Michelle Housey, Peter DeGuire, and Sarah Lyon-Callo are with the Michigan Department of Community Health, Lansing. Lu Wang is with the Department of Biostatistics, University of Michigan, Ann Arbor. Wendy Marder, W. Joseph McCune, and Emily C. Somers are with the Department of Internal Medicine, University of Michigan, Ann Arbor. Charles G. Helmick is with the Centers for Disease Control and Prevention, Atlanta, GA. Caroline Gordon is with the University of Birmingham, Birmingham, UK. J. Patricia Dhar is with the Central Michigan University College of Medicine, Mount Pleasant. James Leisen is with the Henry Ford Health System, Division of Rheumatology, Detroit, MI
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Abstract
A dose-dependent combination of environmental exposures, estrogenic hormones and genetic predisposition is thought to be required for lupus to develop and flare, but how the environment modifies the immune system in genetically predisposed people is unclear. Current evidence indicates that environmental agents that inhibit DNA methylation can convert normal antigen-specific CD4+ T lymphocytes into autoreactive, cytotoxic, pro-inflammatory cells that are sufficient to cause lupus-like autoimmunity in animal models, and that the same changes in DNA methylation characterize CD4+ T cells from patients with active lupus. Environmental agents implicated in inhibiting T-cell DNA methylation include the lupus-inducing drugs procainamide and hydralazine, as well as diet, and agents causing oxidative stress, such as smoking, UV light exposure, and infections, which have been associated with lupus onset or disease activity. Other studies demonstrate that demethylated T cells cause only anti-DNA antibodies in mice lacking a genetic predisposition to lupus, but are sufficient to cause lupus-like autoimmunity in genetically predisposed mice and likely people, and that estrogens augment the disease. Collectively, these studies suggest that environmental agents that inhibit DNA methylation, together with lupus genes and estrogens or endocrine disruptors, combine in a dose-dependent fashion to cause lupus flares.
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Affiliation(s)
- E C Somers
- 1Department of Medicine, University of Michigan, Ann Arbor, USA
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Knight JS, Blayney DW, Somers EC. Patients with systemic lupus erythematosus and haematological malignancy at a tertiary care centre: timing, histopathology and therapy. Lupus Sci Med 2014; 1:e000051. [PMID: 25452880 PMCID: PMC4246917 DOI: 10.1136/lupus-2014-000051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/23/2014] [Accepted: 10/26/2014] [Indexed: 01/15/2023]
Abstract
Objectives Patients with systemic lupus erythematosus (SLE) are at higher risk of haematological malignancies (HMs) than the general population. Most reports have focused on HM diagnosed after SLE, and have excluded concurrent and preceding diagnoses. Information on response to therapy is also limited. Methods We identified 13 296 cases of HM and 10 539 potential patients with SLE at our centre; 45 patients were confirmed to have HM and SLE. Our retrospective case series was based on these 45 patients. Results Of the 45 patients, 64% were diagnosed with HM ≥1 year after diagnosis with SLE, and 36% with HM before or concurrent with SLE. Of the 29 patients with HM after SLE, 13 had diffuse large B cell lymphoma (DLBCL), 6 indolent lymphoma, 4 leukaemia, 3 Hodgkin's disease, and 1 each Burkitt's lymphoma, T cell lymphoma and multiple myeloma. Eleven patients with DLBCL were treated with cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone (CHOP) or rituximab-CHOP; hydroxydaunorubicin, oncovin and prednisone; only four achieved durable remission. Of the 16 patients diagnosed with HM before or concurrent with SLE, 9 were diagnosed with HM more than 2 years before SLE and tended to be in remission prior to SLE diagnosis. Seven patients were diagnosed with HM and SLE concurrently; in terms of their HM, six achieved remission or stable disease. Conclusions In summary, DLBCL was the most common type of lymphoma in patients diagnosed with HM after SLE; these patients presented with advanced-stage disease and had poor outcomes. In contrast, patients diagnosed with HM before or concurrent with SLE had early stage disease and typically achieved remission.
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Affiliation(s)
- Jason S Knight
- Department of Internal Medicine, Division of Rheumatology , University of Michigan , Ann Arbor, Michigan , USA
| | - Douglas W Blayney
- Stanford Cancer Center, Stanford School of Medicine , Stanford, California , USA
| | - Emily C Somers
- Department of Internal Medicine, Division of Rheumatology , University of Michigan , Ann Arbor, Michigan , USA ; Department of Environmental Health Sciences , University of Michigan , Ann Arbor, Michigan , USA ; Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor, Michigan , USA
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Basu N, Tutino R, Zhang Z, Cantonwine DE, Goodrich JM, Somers EC, Rodriguez L, Schnaas L, Solano M, Mercado A, Peterson K, Sánchez BN, Hernández-Avila M, Hu H, Maria Téllez-Rojo M. Mercury levels in pregnant women, children, and seafood from Mexico City. Environ Res 2014; 135:63-9. [PMID: 25262076 PMCID: PMC4262596 DOI: 10.1016/j.envres.2014.08.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/09/2014] [Accepted: 08/13/2014] [Indexed: 05/20/2023]
Abstract
BACKGROUND Mercury is a global contaminant of concern though little is known about exposures in México. OBJECTIVES To characterize mercury levels in pregnant women, children, and commonly consumed seafood samples. METHODS Use resources of the Early Life Exposures in Mexico to Environmental Toxicants (ELEMENT) birth cohorts to measure total mercury levels in archived samples from 348 pregnant women (blood from three trimesters and cord blood), 825 offspring (blood, hair, and urine) and their mothers (hair), and 91 seafood and canned tuna samples from Mexico City. RESULTS Maternal blood mercury levels correlated across three trimesters and averaged 3.4 μg/L. Cord blood mercury averaged 4.7 μg/L and correlated with maternal blood from trimester 3 (but not trimesters 1 and 2). In children, blood, hair and urine mercury levels correlated and averaged 1.8 μg/L, 0.6 μg/g, and 0.9 μg/L, respectively. Hair mercury was 0.5 μg/g in mothers and correlated with child's hair. Mean consumption of canned tuna, fresh fish, canned sardine, and shellfish was 3.1, 2.2, 0.5, and 1.0 times per month respectively in pregnant women. Mean mercury content in 7 of 23 seafood species and 5 of 9 canned tuna brands purchased exceeded the U.S. EPA guidance value of 0.3 μg/g. CONCLUSIONS Mercury exposures in pregnant women and children from Mexico City, via biomarker studies, are generally 3-5 times greater than values reported in population surveys from the U.S., Canada, and elsewhere. In particular, mercury levels in 29-39% of the maternal participants exceeded the biomonitoring guideline associated with the U.S. EPA reference dose for mercury.
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Affiliation(s)
- Niladri Basu
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Quebec, Canada H9X 2T9.
| | - Rebecca Tutino
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Zhenzhen Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - David E Cantonwine
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Division of Maternal-Fetal Medicine, Brigham & Women׳s Hospital, Harvard School of Medicine, Boston, MA, USA
| | - Jaclyn M Goodrich
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Emily C Somers
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Lauren Rodriguez
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Lourdes Schnaas
- Division of Public Health, National Institute of Perinatology, Mexico, D.F., Mexico
| | - Maritsa Solano
- Division of Statistics, Center for Evaluation Research and Surveys, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Adriana Mercado
- Division of Statistics, Center for Evaluation Research and Surveys, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | - Karen Peterson
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Brisa N Sánchez
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Howard Hu
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Martha Maria Téllez-Rojo
- Division of Statistics, Center for Evaluation Research and Surveys, National Institute of Public Health, Cuernavaca, Morelos, Mexico
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Marder W, Romero VC, Ganser MA, Hyzy MA, Gordon C, McCune WJ, Somers EC. Increased usage of special educational services by children born to mothers with systemic lupus erythematosus and antiphospholipid antibodies. Lupus Sci Med 2014; 1:e000034. [PMID: 25379194 PMCID: PMC4213825 DOI: 10.1136/lupus-2014-000034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 06/20/2014] [Accepted: 06/22/2014] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Surveys of long-term health and developmental outcomes of children born to mothers with systemic lupus erythematosus (SLE) have suggested an increase in learning disabilities among these children. We performed this observational study to investigate the relationship between maternal autoantibodies and antiphospholipid antibody syndrome (APS) in maternal lupus patients and neurocognitive development among their offspring. METHODS SLE mothers with at least one live birth postlupus diagnosis were enrolled. Data on maternal medical/obstetric history and children's perinatal/medical history were collected by structured interview and medical record reviews. The primary outcome was requirement for special educational (SE) services, a proxy for developmental delays. Multiple logistic regression modelling was used to examine associations between APS and autoantibodies with SE usage, accounting for SLE disease severity and potential confounders. RESULTS Data on 38 mothers and 60 offspring were analysed: SE service usage was reported for 15 of 60 (25%) offspring. Maternal APS history was significantly associated with increased use of SE services among offspring, including after adjustment for lupus anticoagulant (LA) positivity and potential confounders (OR 5.5-9.4 for delays age ≥2; p<0.05). The presence of LA, but not other antiphospholipid antibodies, was also associated with increased SE services usage. CONCLUSIONS Maternal APS and LA were independently associated with increased usage of special educational services among offspring of women with SLE.
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Affiliation(s)
- Wendy Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vivian C Romero
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Martha A Ganser
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Margaret A Hyzy
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caroline Gordon
- School of Immunity and Infection, University of Birmingham, Birmingham, UK
| | - W J McCune
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily C Somers
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
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Somers EC, Marder W, Cagnoli P, Lewis EE, DeGuire P, Gordon C, Helmick CG, Wang L, Wing JJ, Dhar JP, Leisen J, Shaltis D, McCune WJ. Population-based incidence and prevalence of systemic lupus erythematosus: the Michigan Lupus Epidemiology and Surveillance program. Arthritis Rheumatol 2014; 66:369-78. [PMID: 24504809 DOI: 10.1002/art.38238] [Citation(s) in RCA: 286] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 10/15/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To estimate the incidence and prevalence of systemic lupus erythematosus (SLE) in a sociodemographically diverse southeastern Michigan source population of 2.4 million people. METHODS SLE cases fulfilling the American College of Rheumatology classification criteria (primary case definition) or meeting rheumatologist-judged SLE criteria (secondary definition) and residing in Wayne or Washtenaw Counties during 2002-2004 were included. Case finding was performed from 6 source types, including hospitals and private specialists. Age-standardized rates were computed, and capture-recapture was performed to estimate underascertainment of cases. RESULTS The overall age-adjusted incidence and prevalence (ACR definition) per 100,000 persons were 5.5 (95% confidence interval [95% CI] 5.0-6.1) and 72.8 (95% CI 70.8-74.8). Among females, the incidence was 9.3 per 100,000 persons and the prevalence was 128.7 per 100,000 persons. Only 7 cases were estimated to have been missed by capture-recapture, adjustment for which did not materially affect the rates. SLE prevalence was 2.3-fold higher in black persons than in white persons, and 10-fold higher in females than in males. Among incident cases, the mean ± SD age at diagnosis was 39.3 ± 16.6 years. Black SLE patients had a higher proportion of renal disease and end-stage renal disease (ESRD) (40.5% and 15.3%, respectively) as compared to white SLE patients (18.8% and 4.5%, respectively). Black patients with renal disease were diagnosed as having SLE at younger age than white patients with renal disease (mean ± SD 34.4 ± 14.9 years versus 41.9 ± 21.3 years; P = 0.05). CONCLUSION SLE prevalence was higher than has been described in most other population-based studies and reached 1 in 537 among black female persons. There were substantial racial disparities in the burden of SLE, with black patients experiencing earlier age at diagnosis, >2-fold increases in SLE incidence and prevalence, and increased proportions of renal disease and progression to ESRD as compared to white patients.
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Abstract
PURPOSE OF REVIEW To review the association of pregnancy with the risk of subsequent development of rheumatic autoimmune diseases in women, including rheumatoid arthritis (RA), systemic lupus erythematosus, and scleroderma. RECENT FINDINGS There is a small but growing literature related to the risk of autoimmune rheumatic disease in association with pregnancy history. However, results conflict both in terms of the direction and magnitude of risk of disease in relationship to prior pregnancy history. Although anecdotal evidence tends to favor the premise that pregnancy is protective against certain diseases, such as RA, the heterogeneity of results precludes the ability to confirm an association in either direction. There is indication that time elapsed since pregnancy may influence risk, with the postpartum year being of particular relevance. SUMMARY To date, a clear pattern has not emerged regarding pregnancy and the future risk of autoimmune rheumatic diseases. This topic requires greater study, and given the strong female preponderance of these diseases, future research efforts should seek to resolve this important issue.
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Affiliation(s)
- Wendy Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily C Somers
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Marder W, Ganser MA, Romero V, Hyzy MA, Gordon C, McCune WJ, Somers EC. In utero azathioprine exposure and increased utilization of special educational services in children born to mothers with systemic lupus erythematosus. Arthritis Care Res (Hoboken) 2013; 65:759-66. [PMID: 23139238 PMCID: PMC3572294 DOI: 10.1002/acr.21888] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 10/14/2012] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Azathioprine (AZA) is recognized among immunosuppressive medications as relatively safe during pregnancy for women with systemic lupus erythematosus (SLE) requiring aggressive treatment. This pilot study aimed to determine whether SLE therapy during pregnancy was associated with developmental delays in offspring. METHODS This cohort study included SLE patients with at least one live birth postdiagnosis. Medical histories were obtained via interviews and chart review. Multiple logistic regression was used to examine associations between SLE therapy during pregnancy and maternal report of special educational (SE) requirements (as proxy for developmental delays) among offspring. Propensity scoring (incorporating corticosteroid use, lupus flare, and lupus nephritis) was used to account for disease severity. RESULTS Of 60 eligible offspring from 38 mothers, 15 required SE services, the most common indication for which was speech delay. Seven (54%) of the 13 children with in utero AZA exposure utilized SE services versus 8 (17%) of 47 nonexposed children (P < 0.01). After adjustment for pregnancy duration, small for gestational age, propensity score, maternal education level, and antiphospholipid antibody syndrome, AZA was significantly associated with SE utilization occurring from age 2 years onward (odds ratio 6.6, 95% confidence interval 1.0-43.3), and bordered on significance for utilization at any age or age <2 years. CONCLUSION AZA exposure during SLE pregnancy was independently associated with increased SE utilization in offspring, after controlling for confounders. Further research is indicated to fully characterize developmental outcomes among offspring with in utero AZA exposure. Vigilance and early interventions for suspected developmental delays among exposed offspring may be warranted.
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Affiliation(s)
- Wendy Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Martha A Ganser
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Vivian Romero
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Margaret A Hyzy
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Caroline Gordon
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, UK
| | - WJ McCune
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Emily C Somers
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Kalunian KC, Chatham WW, Massarotti EM, Reyes-Thomas J, Harris C, Furie RA, Chitkara P, Putterman C, Gross RL, Somers EC, Kirou KA, Ramsey-Goldman R, Hsieh C, Buyon JP, Dervieux T, Weinstein A. Measurement of cell-bound complement activation products enhances diagnostic performance in systemic lupus erythematosus. ACTA ACUST UNITED AC 2012; 64:4040-7. [DOI: 10.1002/art.34669] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/07/2012] [Indexed: 12/20/2022]
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Marder W, Fisseha S, Ganser MA, Somers EC. Ovarian Damage During chemotherapy in Autoimmune Diseases: Broad Health Implications beyond Fertility. Clin Med Insights Reprod Health 2012; 2012:9-18. [PMID: 23970822 PMCID: PMC3747568 DOI: 10.4137/cmrh.s10415] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Women with autoimmune diseases such as lupus, scleroderma, and vasculitis receiving cyclophosphamide for severe disease manifestations risk primary ovarian insufficiency(POI) due to gonadotoxicity of this therapy. In addition to loss of reproductive potential, POI is associated with increased risk of morbidity and mortality. Practitioners caring for women requiring gonadotoxic therapies should be familiar with long-term health implications of POI and strategies for ovarian preservation. Accumulating evidence supports the effectiveness of adjunctive gonadotropin releasing hormone analog (GnRH-a) for ovarian protection during gonadotoxic therapy in cancer and autoimmune populations. GnRH-a is less costly and invasive than assisted reproductive technologies used for achievement of future pregnancies, but is not Food and Drug Administration approved for ovarian preservation. This review focuses on POI comorbidities and strategies for mitigation of related sequelae, which can accumulate over decades of hypoesteogenism. These issues are arguably more pronounced for women with chronic autoimmune diseases, in whom superimposed POI further heightens risks of cardiovascular disease and osteoporosis. Therefore, even if future pregnancy is not desired, ovarian protection during gonadotoxic therapy should be a major goal of disease management.
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Affiliation(s)
- Wendy Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
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Somers EC, Marder W, Cagnoli P, Lewis EE, DeGuire P, Gordon C, Helmick CG, Wang L, Wing JJ, Dhar JP, Liesen J, McCune WJ. 'MiLES' population-based survey of the incidence and prevalence of systemic lupus erythematosus in Southeastern Michigan. Arthritis Res Ther 2012. [PMCID: PMC3467525 DOI: 10.1186/ar3982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Marder W, McCune WJ, Wang L, Wing JJ, Fisseha S, McConnell DS, Christman GM, Somers EC. Adjunctive GnRH-a treatment attenuates depletion of ovarian reserve associated with cyclophosphamide therapy in premenopausal SLE patients. Gynecol Endocrinol 2012; 28:624-7. [PMID: 22296584 PMCID: PMC3396751 DOI: 10.3109/09513590.2011.650752] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We measured antimullerian hormone (AMH), a marker of ovarian reserve, in women with lupus treated with cyclophosphamide (CYC) (group I), CYC plus gonadotropin-releasing hormone agonist (GnRH-a) (group II) or neither (group III). We hypothesized that AMH would be diminished in women exposed to CYC versus women receiving adjunctive GnRH-a treatment or no CYC exposure. METHODS Forty-eight premenopausal lupus patients were retrospectively divided into three treatment groups: CYC alone (group I, n = 11), CYC + GnRH-a (group II, n = 10) and neither (group III, n = 27). Serum AMH levels between groups were compared using a nonparametric test (Wilcoxon rank-sum). Multiple linear regression adjusting for age was performed. RESULTS AMH (ng/mL) levels at the last collection were significantly lower in group I versus group III (mean ± SD: 0.18 ± 0.20 group I vs 1.33 ± 1.59 group III; p = 0.015), and versus group II (mean ± SD: 0.86 ± 1.06; p = 0.018). When centered on age 30 years, average AMH levels for group I, group II and group III were 0.20, 0.44 and 1.00, respectively. When adjusted for age, AMH between all groups was significantly different (p<0.0001). CONCLUSION Posttreatment AMH levels were significantly higher among patients receiving CYC + GnRH-a compared to CYC alone, suggesting that GnRH-a coadministration mitigates CYC-induced ovarian injury.
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Affiliation(s)
- W Marder
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, MI 48109-5358, USA.
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Somers EC, Zhao W, Lewis EE, Wang L, Wing JJ, Sundaram B, Kazerooni EA, McCune WJ, Kaplan MJ. Type I interferons are associated with subclinical markers of cardiovascular disease in a cohort of systemic lupus erythematosus patients. PLoS One 2012; 7:e37000. [PMID: 22606325 PMCID: PMC3351452 DOI: 10.1371/journal.pone.0037000] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 04/11/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) patients have a striking increase in cardiovascular (CV) comorbidity not fully explained by the Framingham risk score. Recent evidence from in vitro studies suggests that type I interferons (IFN) could promote premature CV disease (CVD) in SLE. We assessed the association of type I IFN signatures with functional and anatomical evidence of vascular damage, and with biomarkers of CV risk in a cohort of lupus patients without overt CVD. METHODOLOGY/PRINCIPAL FINDINGS Serum type I IFN activity (induction of five IFN-inducible genes; IFIGs) from 95 SLE patient and 38 controls was quantified by real-time PCR. Flow mediated dilatation (FMD) of the brachial artery and carotid intima media thickness (CIMT) were quantified by ultrasound, and coronary calcification by computed tomography. Serum vascular biomarkers were measured by ELISA. We evaluated the effect of type I IFNs on FMD, CIMT and coronary calcification by first applying principal components analysis to combine data from five IFIGs into summary components that could be simultaneously modeled. Three components were derived explaining 97.1% of the total IFIG variation. Multivariable linear regression was utilized to investigate the association between the three components and other covariates, with the outcomes of FMD and CIMT; zero-inflated Poisson regression was used for modeling of coronary calcification. After controlling for traditional CV risk factors, enhanced serum IFN activity was significantly associated with decreased endothelial function in SLE patients and controls (p<0.05 for component 3), increased CIMT among SLE patients (p<0.01 for components 1 and 2), and severity of coronary calcification among SLE patients (p<0.001 for component 3). CONCLUSIONS Type I IFNs are independently associated with atherosclerosis development in lupus patients without history of overt CVD and after controlling for Framingham risk factors. This study further supports the hypothesis that type I IFNs promote premature vascular damage in SLE.
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Affiliation(s)
- Emily C. Somers
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Wenpu Zhao
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Emily E. Lewis
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Lu Wang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Jeffrey J. Wing
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Baskaran Sundaram
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - Ella A. Kazerooni
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States of America
| | - W. Joseph McCune
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail: (WJM); (MJK)
| | - Mariana J. Kaplan
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States of America
- * E-mail: (WJM); (MJK)
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Somers EC, Antonsen S, Pedersen L, Sørensen HT. Parental history of lupus and rheumatoid arthritis and risk in offspring in a nationwide cohort study: does sex matter? Ann Rheum Dis 2012; 72:525-9. [PMID: 22586159 DOI: 10.1136/annrheumdis-2011-201165] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To examine the familial risk of systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), including juvenile rheumatoid/idiopathic arthritis (JRA), in a population-based setting; and to determine whether patterns of transmission differ according to the sex of the parent or offspring, in order to provide insight into the potential impact of X-chromosomal factors on sex disparities in these autoimmune diseases. METHODS A population-based cohort of parent-offspring triads from Denmark (1977-2010) was established. SLE and RA incidence rates among offspring were calculated, and Cox regression was performed to assess the sex-specific risk of disease in offspring according to maternal or paternal disease history. RESULTS Among 3 513 817 parent-offspring triads, there were 1258 SLE cases among offspring (1095 female, 163 male) and 9118 cases of RA/JRA (6086 female, 3032 male). Among female offspring, SLE risk was nearly the same according to maternal (HR 14.1) or paternal (HR 14.5) history (p=NS); likewise among male offspring, risk according to maternal (HR 5.5) and paternal (no cases) history were similar (p=NS). For RA, all risk estimates were similar, regardless of the sex of the offspring or parent (HR 2.6-2.9; p=NS). CONCLUSIONS The authors quantified the familial risk of SLE and RA in a nationwide cohort study. For both diseases, transmission was comparable among both female and male offspring of maternal and paternal cases. These data provide evidence at the population level that X-chromosomal factors do not play a major role in sex disparities associated with the risk of SLE and RA.
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Affiliation(s)
- Emily C Somers
- Correspondence to Emily C Somers, University of Michigan, Division of Rheumatology, 24 Frank Lloyd Wright Drive, PO Box 481, Ann Arbor, Michigan 48109-5358, USA.
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Sawalha AH, Wang L, Nadig A, Somers EC, McCune WJ, Hughes T, Merrill JT, Scofield RH, Strickland FM, Richardson B. Sex-specific differences in the relationship between genetic susceptibility, T cell DNA demethylation and lupus flare severity. J Autoimmun 2012; 38:J216-22. [PMID: 22305513 PMCID: PMC3313010 DOI: 10.1016/j.jaut.2011.11.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Revised: 11/19/2011] [Accepted: 11/22/2011] [Indexed: 12/21/2022]
Abstract
Lupus is less common in men than women, and the reason is incompletely understood. Current evidence indicates that lupus flares when genetically predisposed individuals encounter environmental agents that trigger the disease, and that the environmental contribution is mediated at least in part by T cell DNA demethylation. We hypothesized that lupus disease activity is directly related to total genetic risk and inversely related to T cell DNA methylation levels in each patient. Since women are predisposed to lupus in part because of their second X chromosome, we also hypothesized that men would require a greater genetic risk, a greater degree of autosomal T cell DNA demethylation, or both, to achieve a lupus flare equal in severity to women. Genetic risk was determined by genotyping men and women with lupus across 32 confirmed lupus susceptibility loci. The methylation status of two autosomal genes known to demethylate in T cells in proportion to disease activity, KIR2DL4 (KIR) and PRF1, was measured by bisulfite sequencing. Lupus disease activity was determined by the SLEDAI. Interactions between genetic score, T cell DNA demethylation, and the SLEDAI score were compared between the men and women by regression analysis. Combining the degree of DNA demethylation with the genetic risk score for each patient demonstrated that the (genetic risk)/(DNA methylation) ratio increased directly with disease activity in both men and women with lupus. Importantly, men required a greater (genetic risk)/(DNA methylation) ratio to achieve a SLEDAI score equivalent to women (P = 0.010 for KIR and P = 0.0054 for PRF1). This difference was not explained by a difference in the genetic risk or T cell DNA demethylation alone, suggesting a genetic-epigenetic interaction. These results suggest that genetic risk and T cell DNA demethylation interact in lupus patients to influence the severity of lupus flares, and that men require a higher genetic risk and/or greater degree of T cell DNA demethylation to achieve a lupus flare equal in severity to women.
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Affiliation(s)
- Amr H Sawalha
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
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Schiopu E, Phillips K, MacDonald PM, Crofford LJ, Somers EC. Predictors of survival in a cohort of patients with polymyositis and dermatomyositis: effect of corticosteroids, methotrexate and azathioprine. Arthritis Res Ther 2012; 14:R22. [PMID: 22284862 PMCID: PMC3392815 DOI: 10.1186/ar3704] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Revised: 12/05/2011] [Accepted: 01/27/2012] [Indexed: 11/30/2022] Open
Abstract
Introduction The idiopathic inflammatory myopathies are rare diseases for which data regarding the natural history, response to therapies and factors affecting mortality are needed. We performed this study to examine the effects of treatment and clinical features on survival in polymyositis and dermatomyositis patients. Methods A total of 160 consecutive patients (77 with polymyositis and 83 with dermatomyositis) seen at the University of Michigan from 1997 to 2003 were included. Medical records were abstracted for clinical, laboratory and therapeutic data, including initial steroid regimen and immunosuppressive use. State vital records were utilized to derive mortality and cause of death data. Survival was modeled by left-truncated Kaplan-Meier estimation and Cox regression. Results The 5- and 10-year survival estimates were 77% (95% CI = 66 to 85), and 62% (95% CI = 48 to 73), respectively, and the rates were similar for polymyositis and dermatomyositis. Survival between the sexes was similar through 5 years and significantly lower thereafter for males (10-year survival: 18% male, 73% female; P = 0.002 for 5- to 10-year interval). The sex disparity was restricted to the polymyositis group. Increased age at diagnosis and non-Caucasian race were associated with lower survival. Intravenous versus oral corticosteroid use was associated with a higher risk of death among Caucasians (HR = 10.6, 95% CI = 2.1 to 52.8). Early survival between patients treated with methotrexate versus azathioprine was similar, but survival at 10 years was higher for the methotrexate-treated group (76% vs 52%, P = 0.046 for 5- to 10-year interval). Conclusions Patients treated initially with intravenous corticosteroids had higher mortality, which was likely related to disease severity. Both methotrexate and azathioprine showed similar early survival benefits as first-line immunosuppressive drugs. Survival was higher between 5 and 10 years in the methotrexate-treated group, but could not be confirmed in multivariable modeling for the full follow-up period. Other important predictors of long-term survival included younger age, female sex and Caucasian race.
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Affiliation(s)
- Elena Schiopu
- Department of Internal Medicine, Division of Rheumatology, University of Michigan, 1500 East Medical Center Drive, 3918 TC, Ann Arbor, MI 48109-5358, USA
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Schoonen WM, Thomas SL, Somers EC, Smeeth L, Kim J, Evans S, Hall AJ. Do selected drugs increase the risk of lupus? A matched case-control study. Br J Clin Pharmacol 2011; 70:588-96. [PMID: 20840450 DOI: 10.1111/j.1365-2125.2010.03733.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AIM To investigate the association between risk of lupus and exposure to selected drugs implicated in risk of lupus in a number of case reports. METHODS In this matched nested case-control study we utilized primary care data from the UK General Practice Research Database recorded between 1987 and 2001. Cases with at least one medical code for systemic lupus erythematosus or drug-induced lupus in their computerized records were matched to controls without a medical code for lupus or any other autoimmune disorder. Using conditional logistic regression we computed odds ratios (OR) and 95% confidence intervals (CI) for risk of lupus associated with exposure to selected drugs. RESULTS There were 875 incident cases, of which 12% (n= 107) had evidence of a prescription for one or more of the suspected drugs, and 3632 matched controls. For some drugs, prescriptions were too uncommon to be able to estimate associated risk of lupus. Despite small numbers of exposed patients and low statistical precision we observed an increased risk of lupus for hydralazine (OR = 6.62, 95% CI 1.03, 42.74), minocycline (OR = 4.23, 95% CI 2.65, 6.75) and carbamazepine (OR = 1.88, 95% CI 1.09, 3.22). There was some indication that the effect of carbamazepine was restricted to women (P for interaction by gender = 0.047). CONCLUSION This study shows that even those drugs suggested by case reports as causing lupus cannot all be clearly shown to be associated, even in a very large population-based database. Our findings support causal relationships for carbamazepine, minocycline and possibly hydralazine. Overall, drugs do not seem to be a major cause of lupus.
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Affiliation(s)
- W Marieke Schoonen
- Department of International Epidemiology, Amgen Ltd, Uxbridge Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Webb R, Kelly JA, Somers EC, Hughes T, Kaufman KM, Sanchez E, Nath SK, Bruner G, Alarcón-Riquelme ME, Gilkeson GS, Kamen DL, Richardson BC, Harley JB, Sawalha AH. Early disease onset is predicted by a higher genetic risk for lupus and is associated with a more severe phenotype in lupus patients. Ann Rheum Dis 2010; 70:151-6. [PMID: 20881011 DOI: 10.1136/ard.2010.141697] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is a chronic, multiorgan, autoimmune disease that affects people of all ages and ethnicities. OBJECTIVES To explore the relationship between age at disease onset and many of the diverse manifestations of SLE. Additionally, to determine the relationship between age of disease onset and genetic risk in patients with SLE. METHODS The relationship between the age at disease onset and SLE manifestations were explored in a multi-racial cohort of 1317 patients. Patients with SLE were genotyped across 19 confirmed genetic susceptibility loci for SLE. Logistic regression was used to determine the relationships between the number of risk alleles present and age of disease onset. RESULTS Childhood-onset SLE had higher odds of proteinuria, malar rash, anti-dsDNA antibody, haemolytic anaemia, arthritis and leucopenia (OR=3.03, 2.13, 2.08, 2.50, 1.89, 1.53, respectively; p values <0.0001, 0.0004, 0.0005, 0.0024, 0.0114, 0.045, respectively). In female subjects, the odds of having cellular casts were 2.18 times higher in childhood-onset than in adult-onset SLE (p=0.0027). With age of onset ≥50, the odds of having proteinuria, cellular casts, anti-nRNP antibody, anti-Sm antibody, anti-dsDNA antibody and seizures were reduced. However, late adult-onset patients with SLE have higher odds of developing photosensitivity than early adult-onset patients. Each SLE-susceptibility risk allele carried within the genome of patients with SLE increased the odds of having a childhood-onset disease in a race-specific manner: by an average of 48% in Gullah and 25% in African-Americans, but this was not significant in Hispanic and European-American lupus patients. CONCLUSIONS The genetic contribution towards predicting early-onset disease in patients with SLE is quantified for the first time. A more severe SLE phenotype is found in patients with early-onset disease in a large multi-racial cohort, independent of gender, race and disease duration.
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Affiliation(s)
- Ryan Webb
- Arthritis & Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
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Marder W, Somers EC, Kaplan MJ, Anderson MR, Lewis EE, McCune WJ. Effects of prasterone (dehydroepiandrosterone) on markers of cardiovascular risk and bone turnover in premenopausal women with systemic lupus erythematosus: a pilot study. Lupus 2010; 19:1229-36. [PMID: 20530522 DOI: 10.1177/0961203310371156] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
DHEA (dehydroepiandrosterone) is a weak androgen with proposed efficacy in the treatment of mild to moderate lupus, and possible beneficial effects on cardiovascular risk and bone mineral density. We hypothesized that treatment with 200 mg a day of Prasterone (DHEA) would improve pre-clinical measures of atherosclerosis: flow-mediated dilatation (FMD), nitroglycerin-mediated dilatation (NMD), and circulating apoptotic endothelial cells (CD 146(AnnV +)), as well markers of bone metabolism. Thirteen premenopausal female patients with Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) <or=8 were enrolled in a double-blind placebo-controlled crossover trial for 22 weeks with a 6-week washout between treatment periods. Results reveal high-density lipoprotein (HDL) levels significantly decreased with Prasterone (48.5 versus 56.3 with placebo, p <or= 0.001), and there was a trend towards impairment of endothelial function with Prasterone (brachial artery FMD 3.4% versus 4.4% with placebo, mean difference -1.07, NMD 19.5% versus 24.4% with placebo, mean difference -4.9, p = NS). There were no differences between groups in SLEDAI, CD146( AnnV+) cells, or receptor activator for nuclear factor kB ligand (RANKL)/osteoprotegerin, although RANKL was higher after treatment with Prasterone (mean difference -29.5 units; p = 0.097). This pilot study does not support the use of Prasterone in mild lupus for prevention of atherosclerosis or osteoporosis, and confirms other findings of potentially harmful effects on lipids.
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Affiliation(s)
- W Marder
- University of Michigan Health System, Ann Arbor, MI, USA.
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Ike RW, Somers EC, Arnold EL, Arnold WJ. Ultrasound of the knee during voluntary quadriceps contraction: a technique for detecting otherwise occult effusions. Arthritis Care Res (Hoboken) 2010; 62:725-9. [PMID: 20461790 PMCID: PMC5596890 DOI: 10.1002/acr.20047] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe 1) a technique that can detect synovial effusions not seen on static ultrasound (US) examination and 2) the characteristics of patients with knee osteoarthritis (OA) for whom this technique proved useful. METHODS From reviewed records of 76 patients with knee OA (112 knees) that we had seen for US-guided injections over a defined period, we found 45 knees with no detectable effusion on static US, of which 18 (14 patients) showed fluid when scanned during voluntary quadriceps contraction. For all patients, we had recorded effusion features (physical examination, presence and size on US), and success of joint entry was determined by getting synovial fluid and/or seeing an air echo or inflow of injected material. RESULTS The 14 patients we studied were obese (mean +/- SEM body mass index 32.7 +/- 2.3 kg/m(2); 3 morbidly obese), with moderate to severe OA by radiography in most (Kellgren/Lawrence class 3 or 4 in 10 of 14 knees for which radiographs were available). The suprapatellar synovial space seen by US was small (mean +/- SEM depth 0.38 +/- 0.04 cm). Arthrocentesis obtained 0.5-16 ml of synovial fluid (mean +/- SEM 2.9 +/- 0.6 ml), which correlated with the depth of effusion as seen on US with the quadriceps in maximum contraction (Spearman's rho = 0.5597, P = 0.0157). In 4 knees where arthrocentesis failed to retrieve fluid, we observed at injection the inflow of material and a linear air echo. CONCLUSION US of the knee during voluntary quadriceps contraction can find effusions not detectable on static US. Such effusions provide targets for accurate aspiration and injection that would not be appreciated with static US.
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Affiliation(s)
- Robert W Ike
- Rheumatology Division, University of Michigan, Ann Arbor, MI 48109-0358, USA.
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Sam Lim S, Drenkard C, McCune WJ, Helmick CG, Gordon C, DeGuire P, Bayakly R, Somers EC. Population-based lupus registries: Advancing our epidemiologic understanding. ACTA ACUST UNITED AC 2009; 61:1462-6. [DOI: 10.1002/art.24835] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cooper GS, Bynum MLK, Somers EC. Recent insights in the epidemiology of autoimmune diseases: improved prevalence estimates and understanding of clustering of diseases. J Autoimmun 2009; 33:197-207. [PMID: 19819109 DOI: 10.1016/j.jaut.2009.09.008] [Citation(s) in RCA: 480] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Previous studies have estimated a prevalence of a broad grouping of autoimmune diseases of 3.2%, based on literature review of studies published between 1965 and 1995, and 5.3%, based on national hospitalization registry data in Denmark. We examine more recent studies pertaining to the prevalence of 29 autoimmune diseases, and use these data to correct for the underascertainment of some diseases in the hospitalization registry data. This analysis results in an estimated prevalence of 7.6-9.4%, depending on the size of the correction factor used. The rates for most diseases for which data are available from many geographic regions span overlapping ranges. We also review studies of the co-occurrence of diseases within individuals and within families, focusing on specific pairs of diseases to better distinguish patterns that may result in insights pertaining to shared etiological pathways. Overall, data support a tendency for autoimmune diseases to co-occur at greater than expected rates within proband patients and their families, but this does not appear to be a uniform phenomenon across all diseases. Multiple sclerosis and rheumatoid arthritis is one disease pair that appears to have a decreased chance of coexistence.
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Affiliation(s)
- Glinda S Cooper
- Department of Environmental and Occupational Health, George Washington University School of Public Health and Health Services, Washington, DC 20052, USA.
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Zhao W, Thacker SG, Hodgin JB, Zhang H, Wang JH, Park JL, Randolph A, Somers EC, Pennathur S, Kretzler M, Brosius FC, Kaplan MJ. The peroxisome proliferator-activated receptor gamma agonist pioglitazone improves cardiometabolic risk and renal inflammation in murine lupus. J Immunol 2009; 183:2729-40. [PMID: 19620300 PMCID: PMC2765333 DOI: 10.4049/jimmunol.0804341] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Individuals with systemic lupus erythematosus (SLE) have a striking increase in the risk of premature atherosclerosis, a complication preceded by significant subclinical vascular damage. A proposed mechanism leading to accelerated vascular disease in SLE is an imbalance between vascular damage and repair, as patients with this disease display significant abnormalities in phenotype and function of endothelial progenitor cells. In addition, individuals with SLE have a higher incidence of insulin resistance which may further contribute to the increased cardiovascular risk. This study examined the role of the peroxisome proliferator activated receptor gamma agonist pioglitazone in improving endothelial function, endothelial progenitor cell numbers and functional capacity, metabolic parameters, and disease activity in the lupus-prone murine model New Zealand Black/New Zealand White (NZB x NZW)F(1). Ten-week-old prenephritic female NZB/NZW F(1) mice were exposed to 10 or 25 mg/kg/day of oral pioglitazone or vehicle for 15 or 24 wk. Mice exposed to pioglitazone exhibited pronounced enhancement in endothelial-dependent vasorelaxation of thoracic aortas and in endothelial progenitor cell function, as assessed by the capacity of bone marrow-derived endothelial progenitor cells to differentiate into mature endothelial cells. Pioglitazone-treated mice showed improvement in insulin resistance, adipokine, and lipid profile. Kidneys from pioglitazone-treated mice showed significant decreases in immune complex deposition, renal inflammation, T cell glomerular infiltration, and intrarenal synthesis of TNF-alpha, IL-1beta, and VCAM-1. These results indicate that peroxisome proliferator-activated receptor gamma agonists could serve as important tools in the prevention of premature cardiovascular disease and organ damage in SLE.
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Affiliation(s)
- Wenpu Zhao
- Division of Rheumatology, University of Michigan, Ann Arbor, MI 48109, USA
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