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Muñoz-Grajales C, Barraclough ML, Diaz-Martinez JP, Su J, Bingham K, Kakvan M, Kretzmann RP, Tartaglia MC, Ruttan L, Choi MY, Appenzeller S, Marzouk S, Bonilla D, Katz P, Beaton D, Green R, Gladman DD, Wither J, Touma Z. Serum S100A8/A9 and MMP-9 levels are elevated in systemic lupus erythematosus patients with cognitive impairment. Front Immunol 2024; 14:1326751. [PMID: 38332909 PMCID: PMC10851148 DOI: 10.3389/fimmu.2023.1326751] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/21/2023] [Indexed: 02/10/2024] Open
Abstract
Objective Cognitive impairment (CI) is one of the most common manifestations of Neuropsychiatric Systemic Lupus Erythematosus (NPSLE). Despite its frequency, we have a limited understanding of the underlying immune mechanisms, resulting in a lack of pathways to target. This study aims to bridge this gap by investigating differences in serum analyte levels in SLE patients based on their cognitive performance, independently from the attribution to SLE, and exploring the potential for various serum analytes to differentiate between SLE patients with and without CI. Methods Two hundred ninety individuals aged 18-65 years who met the 2019-EULAR/ACR classification criteria for SLE were included. Cognitive function was measured utilizing the adapted ACR-Neuropsychological Battery (ACR-NB). CI was defined as a z-score of ≤-1.5 in two or more domains. The serum levels of nine analytes were measured using ELISA. The data were randomly partitioned into a training (70%) and a test (30%) sets. Differences in the analyte levels between patients with and without CI were determined; and their ability to discriminate CI from non-CI was evaluated. Results Of 290 patients, 40% (n=116) had CI. Serum levels of S100A8/A9 and MMP-9, were significantly higher in patients with CI (p=0.006 and p=0.036, respectively). For most domains of the ACR-NB, patients with CI had higher S100A8/A9 serum levels than those without. Similarly, S100A8/A9 had a negative relationship with multiple CI tests and the highest AUC (0.74, 95%CI: 0.66-0.88) to differentiate between patients with and without CI. Conclusion In this large cohort of well-characterized SLE patients, serum S100A8/A9 and MMP-9 were elevated in patients with CI. S100A8/A9 had the greatest discriminatory ability in differentiating between patients with and without CI.
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Affiliation(s)
- Carolina Muñoz-Grajales
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Michelle L. Barraclough
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- National Institute for Health and Care Research (NIHR), Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Juan P. Diaz-Martinez
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Jiandong Su
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Kathleen Bingham
- Centre for Mental Health, University Health Network, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Mahta Kakvan
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Roberta Pozzi Kretzmann
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Department of Medicine, Division of Neurology, University of Toronto Krembil Neurosciences Centre, Toronto, ON, Canada
| | - Lesley Ruttan
- Department of Psychology, University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - May Y. Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Simone Appenzeller
- School of Medical Science, Department of Orthopedics, Rheumatology and Traumatology, University of Campinas, São Paulo, Brazil
| | - Sherief Marzouk
- Centre for Mental Health, University Health Network, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Dennisse Bonilla
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Patricia Katz
- Division of Rheumatology, Department of Medicine, and Institute for Health Policy Studies, University of California, San Francisco, Novato, CA, United States
| | - Dorcas Beaton
- Institute for Work and Health, University of Toronto, Toronto, ON, Canada
| | - Robin Green
- Department of Psychology, University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Dafna D. Gladman
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Joan Wither
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, ON, Canada
| | - Zahi Touma
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
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Barraclough M, Howe A, Soberanis A, Kakvan M, Chattu V, Bani‐Fatemi A, Engel L, Vitti M, Nalder E, Goverover Y, Gignac M, Bonilla D, Nielsen W, Anderson N, Tartaglia C, Nowrouzi‐Kia B, Touma Z. The Effects of Systemic Lupus-Related Cognitive Impairments on Activities of Daily Living and Life Role Participation: A Qualitative Framework Study. ACR Open Rheumatol 2024; 6:21-30. [PMID: 37964675 PMCID: PMC10789303 DOI: 10.1002/acr2.11624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 09/30/2023] [Indexed: 11/16/2023] Open
Abstract
OBJECTIVE Cognitive impairment (CI) in systemic lupus erythematosus (SLE) negatively impacts health-related quality of life leading to activity limitations. This qualitative study aimed to (1) explore the effect of SLE-related CI on activities of daily living and life role participation and (2) describe factors influencing activity restriction and life role participation. METHODS Semistructured, in-depth interviews of lived experience of CI in SLE were conducted with 24 participants with SLE. Sociodemographic and clinical data, and objective and subjective cognitive function, were collected to characterize participants. A qualitative thematic content analysis was undertaken guided by a framework analytical approach. RESULTS Participants reported problems in multiple cognitive domains, with multiple perceived causes. CI was felt to impact work, social, domestic, and family life, health, and independence. Five overarching themes were represented in the data: (1) characterization of SLE-reported CI, (2) perceived cause of CI, (3) perceived impact of CI on activities of daily living and life role participation, (4) adaptations for managing CI, and (5) influence of CI adaptations on activities of daily living and life role participation. CONCLUSION This study provides a better understanding of the patient experience of CI in SLE, how it impacts their lives, and what coping strategies they employ. It highlights the long-term challenges those with CI in SLE undergo and provides evidence for the urgent need to implement multidisciplinary treatment options. When managing CI, it may be beneficial to evaluate and understand available psychosocial support resources to help identify and reinforce relevant adaptations to improve health-related quality of life.
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Affiliation(s)
- Michelle Barraclough
- University Health Network, Toronto, Ontario, Canada, and The University of Manchester, NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, and Manchester Academic Health Science CentreManchesterUK
| | - Aaron Howe
- University of TorontoTorontoOntarioCanada
| | | | - Mahta Kakvan
- University Health Network, and University of Toronto Lupus Clinic, Toronto Western HospitalTorontoOntarioCanada
| | | | | | - Lisa Engel
- University of Manitoba, Winnipeg, Manitoba, and Institute for Work and HealthTorontoOntarioCanada
| | - Michelle Vitti
- University Health Network, and University of Toronto Lupus Clinic, Toronto Western HospitalTorontoOntarioCanada
| | | | | | - Monique Gignac
- University Health Network, University of Toronto, and Institute for Work and HealthTorontoOntarioCanada
| | - Dennisse Bonilla
- University Health Network, and University of Toronto Lupus Clinic, Toronto Western HospitalTorontoOntarioCanada
| | - Wils Nielsen
- University of Toronto Lupus Clinic and Western HospitalTorontoOntarioCanada
| | - Nicole Anderson
- University Health Network, and University of Toronto Lupus Clinic, Toronto Western HospitalTorontoOntarioCanada
| | | | | | - Zahi Touma
- University Health Network, and University of Toronto Lupus Clinic, Toronto Western HospitalTorontoOntarioCanada
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Barraclough M, Erdman L, Diaz-Martinez JP, Knight A, Bingham K, Su J, Kakvan M, Grajales CM, Tartaglia MC, Ruttan L, Wither J, Choi MY, Bonilla D, Appenzeller S, Parker B, Goldenberg A, Katz P, Beaton D, Green R, Bruce IN, Touma Z. Systemic lupus erythematosus phenotypes formed from machine learning with a specific focus on cognitive impairment. Rheumatology (Oxford) 2023; 62:3610-3618. [PMID: 36394258 PMCID: PMC10629781 DOI: 10.1093/rheumatology/keac653] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 07/05/2022] [Accepted: 11/07/2022] [Indexed: 11/09/2023] Open
Abstract
OBJECTIVE To phenotype SLE based on symptom burden (disease damage, system involvement and patient reported outcomes), with a specific focus on objective and subjective cognitive function. METHODS SLE patients ages 18-65 years underwent objective cognitive assessment using the ACR Neuropsychological Battery (ACR-NB) and data were collected on demographic and clinical variables, disease burden/activity, health-related quality of life (HRQoL), depression, anxiety, fatigue and perceived cognitive deficits. Similarity network fusion (SNF) was used to identify patient subtypes. Differences between the subtypes were evaluated using Kruskal-Wallis and χ2 tests. RESULTS Of the 238 patients, 90% were female, with a mean age of 41 years (s.d. 12) and a disease duration of 14 years (s.d. 10) at the study visit. The SNF analysis defined two subtypes (A and B) with distinct patterns in objective and subjective cognitive function, disease burden/damage, HRQoL, anxiety and depression. Subtype A performed worst on all significantly different tests of objective cognitive function (P < 0.03) compared with subtype B. Subtype A also had greater levels of subjective cognitive function (P < 0.001), disease burden/damage (P < 0.04), HRQoL (P < 0.001) and psychiatric measures (P < 0.001) compared with subtype B. CONCLUSION This study demonstrates the complexity of cognitive impairment (CI) in SLE and that individual, multifactorial phenotypes exist. Those with greater disease burden, from SLE-specific factors or other factors associated with chronic conditions, report poorer cognitive functioning and perform worse on objective cognitive measures. By exploring different ways of phenotyping SLE we may better define CI in SLE. Ultimately this will aid our understanding of personalized CI trajectories and identification of appropriate treatments.
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Affiliation(s)
- Michelle Barraclough
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Lauren Erdman
- Genetics and Genome Biology, Department of Computer Science, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, University of Toronto, Toronto, ON, Canada
| | - Juan Pablo Diaz-Martinez
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Andrea Knight
- Division of Rheumatology, Hospital for Sick Children, Toronto, ON, Canada
| | - Kathleen Bingham
- Centre for Mental Health, University Health Network, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jiandong Su
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Mahta Kakvan
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Carolina Muñoz Grajales
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | | | - Lesley Ruttan
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Joan Wither
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dennisse Bonilla
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | | | - Ben Parker
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Anna Goldenberg
- Genetics and Genome Biology, Department of Computer Science, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, University of Toronto, Toronto, ON, Canada
| | - Patricia Katz
- University of California, San Francisco, Novato, CA, USA
| | - Dorcas Beaton
- Institute for Work and Health, University of Toronto, Toronto, ON, Canada
| | - Robin Green
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Zahi Touma
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
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Dobrowolski C, Barraclough M, Su J, Tanic M, Bingham K, Ruttan L, Beaton D, Wither J, Tartaglia MC, Sano M, Kakvan M, Bonilla D, Green R, Touma Z. Centrally acting ACE inhibitor (cACEi) and angiotensin receptor blocker (cARB) use and cognitive dysfunction in patients with SLE. Lupus Sci Med 2023; 10:e000923. [PMID: 37429671 PMCID: PMC10335417 DOI: 10.1136/lupus-2023-000923] [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] [Received: 02/22/2023] [Accepted: 05/31/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE Cognitive dysfunction (CD) is detectable in approximately 40% of patients with SLE. Despite this high prevalence, there are no approved pharmacological treatment options for this detrimental condition. Preliminary murine studies show potential for targeting microglial activation as a treatment of SLE-CD, which may be ameliorated with centrally acting ACE inhibitor (cACEi) and angiotensin receptor blocker (cARB) use. The aim of this study is to determine if there is an association of cACEi/cARB use with cognitive function in a human SLE cohort. METHODS The American College of Rheumatology neuropsychological battery was administered to patients with consecutive SLE at a single academic health centre at baseline, 6 and 12 months. Scores were compared with sex-matched and age-matched control subjects. Clinical and demographic data were gathered at each visit. The primary outcome was CD defined as dysfunction in two or more cognitive domains. The primary predictor was a total cumulative dose of cACEi/cARB in milligrams per kilogram, recorded as an equivalent ramipril dose. Odds of CD with respect to cACEi/cARB use were determined through generalised linear mixed modelling. RESULTS A total of 300 patients, representing 676 visits, completed this study. One hundred sixteen (39%) met the criteria for CD. Fifty-three participants (18%) were treated with a cACEi or cARB. Mean cumulative dose was 236 mg/kg (calculated as equivalent ramipril dose). Cumulative cACEi/cARB dose was not protective against SLE-CD. Caucasian ethnicity, current employment status and azathioprine cumulative dose were each associated with reduced odds of SLE-CD. Increasing Fatigue Severity Scale score was associated with increased odds of CD. CONCLUSIONS In a single-centre SLE cohort, cACEi/cARB use was not associated with absence of CD. Many important confounders may have influenced the results of this retrospective study. A randomised trial is required to accurately determine if cACEi/cARB is a potential treatment for SLE-CD.
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Affiliation(s)
- Chrisanna Dobrowolski
- Division of Rheumatology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Michelle Barraclough
- Division of Musculoskeletal & Dermatological Sciences, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Jiandong Su
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Milica Tanic
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kathleen Bingham
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Lesley Ruttan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Dorcas Beaton
- Institute for Work and Health, Toronto, Ontario, Canada
| | - Joan Wither
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Maria Carmela Tartaglia
- University of Toronto, Toronto, Ontario, Canada
- Krembil Neurosciences Centre, University Health Network, Toronto, Ontario, Canada
| | - Mary Sano
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Mahta Kakvan
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Dennisse Bonilla
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Robin Green
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Zahi Touma
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
- Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada
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5
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Dobrowolski C, McGinley J, Fazzari M, Su J, Bingham KS, Anderson N, Ruttan L, Beaton DE, Wither JE, Tartaglia MC, Kakvan M, Bonilla D, Choi MY, Fritzler MJ, Diaz Martinez JP, Katz P, Green R, Putterman C, Touma Z. Association of mycophenolate and azathioprine use with cognitive function in systemic lupus. Rheumatology (Oxford) 2023; 62:1860-1869. [PMID: 36135792 PMCID: PMC10152298 DOI: 10.1093/rheumatology/keac540] [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] [Received: 04/25/2022] [Revised: 08/26/2022] [Accepted: 09/14/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Cognitive dysfunction (CD) is a common manifestation of SLE that can have detrimental consequences for those affected. To date, no treatments have been approved for SLE-CD. This study aims to assess the association of azathioprine (AZA) and mycophenolate (MMF) use with SLE-CD, given that these medications have demonstrated neuroprotective qualities in prior studies. METHODS Consecutive adult SLE patients presenting to a single healthcare center were considered for participation. The ACR neuropsychological battery for SLE was administered to consenting patients at 0, 6 and 12 months. Scores were compared with age- and sex-matched controls. Primary outcome was CD, defined as a z-score ≤-1.5 in two or more cognitive domains. Mixed-effects logistic regression models were constructed to estimate the odds of CD with respect to AZA and MMF use. RESULTS A total of 300 participants representing 676 patient visits completed the study; 114 (38%) met criteria for CD at baseline. The cumulative AZA dose (g/kg) was associated with reduced odds of CD [odds ratio (OR) 0.76 (95% CI 0.58, 0.98), P = 0.04]. Years of AZA treatment was also associated with reduced odds of CD [OR 0.72 (95% CI 0.54, 0.97), P = 0.03]. MMF use was not associated with CD. CONCLUSION AZA use was associated with significantly lower odds of SLE-CD, while MMF use was not. Additional studies are warranted to further investigate the relationship of AZA and SLE-CD.
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Affiliation(s)
- Chrisanna Dobrowolski
- Division of Rheumatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John McGinley
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Melissa Fazzari
- Department of Epidemiology and Population Health and Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jiandong Su
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Kathleen S Bingham
- Centre for Mental Health, University Health Network; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Nicole Anderson
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Lesley Ruttan
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Dorcas E Beaton
- Institute for Work and Health, University of Toronto, Toronto, ON, Canada
| | - Joan E Wither
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | | | - Mahta Kakvan
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Dennisse Bonilla
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Juan Pablo Diaz Martinez
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
| | - Patricia Katz
- University of California, San Francisco, Novato, CA, USA
| | - Robin Green
- University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Chaim Putterman
- Department of Microbiology and Immunology, Albert Einstein School of Medicine, Bronx, NY, USA
- Division of Rheumatology, Albert Einstein College of Medicine, Bronx, NY, USA
- Azrieli School of Medicine, Safed, Israel
- Galillee Medical Center, Nahariya, Israel
| | - Zahi Touma
- University of Toronto Lupus Clinic, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, Toronto, ON, Canada
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6
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Barraclough ML, Diaz-Martinez JP, Knight A, Bingham K, Su J, Kakvan M, Grajales CM, Tartaglia MC, Ruttan L, Wither J, Choi MY, Bonilla D, Anderson N, Appenzeller S, Parker B, Katz P, Beaton D, Green R, Bruce IN, Touma Z. In-person versus virtual administration of the American College of Radiology gold standard cognitive battery in systemic lupus erythematosus: Are they interchangeable? Lupus 2023; 32:737-745. [PMID: 37036020 DOI: 10.1177/09612033231168477] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
OBJECTIVE During the COVID-19 pandemic, many research studies were adapted, including our longitudinal study examining cognitive impairment (CI) in systemic lupus erythematosus (SLE). Cognitive testing was switched from in-person to virtual. This analysis aimed to determine if the administration method (in-person vs. virtual) of the ACR-neuropsychological battery (ACR-NB) affected participant cognitive performance and classification. METHODS Data from our multi-visit, SLE CI study included demographic, clinical, and psychiatric characteristics, and the modified ACR-NB. Three analyses were undertaken for cognitive performance: (1) all visits, (2) non-CI group visits only and (3) intra-individual comparisons. A retrospective preferences questionnaire was given to participants who completed the ACR-NB both in-person and virtually. RESULTS We analysed 328 SLE participants who had 801 visits (696 in-person and 105 virtual). Demographic, clinical, and psychiatric characteristics were comparable except for ethnicity, anxiety and disease-related damage. Across all three comparisons, six tests were consistently statistically significantly different. CI classification changed in 11/71 (15%) participants. 45% of participants preferred the virtual administration method and 33% preferred in-person. CONCLUSIONS Of the 19 tests in the ACR-NB, we identified one or more problems with eight (42%) tests when moving from in-person to virtual administration. As the use of virtual cognitive testing will likely increase, these issues need to be addressed - potentially by validating a virtual version of the ACR-NB. Until then, caution must be taken when directly comparing virtual to in-person test results. If future studies use a mixed administration approach, this should be accounted for during analysis.
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Affiliation(s)
- M L Barraclough
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, 5292The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - J P Diaz-Martinez
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, 7938University of Toronto Lupus Clinic, Toronto, ON, Canada
| | - A Knight
- Division of Rheumatology, 7979Hospital for Sick Children, Toronto, ON, Canada
- Neurosciences and Mental Health Program, SickKids Research Institute, Toronto, ON, Canada
| | - K Bingham
- Centre for Mental Health, 7989University Health Network, Toronto, ON, Canada
- Department of Psychiatry, 7938University of Toronto, Toronto, ON, Canada
| | - J Su
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Division of Rheumatology, 7979Hospital for Sick Children, Toronto, ON, Canada
| | - M Kakvan
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, 7938University of Toronto Lupus Clinic, Toronto, ON, Canada
| | - C Muñoz Grajales
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, 7938University of Toronto Lupus Clinic, Toronto, ON, Canada
| | - M C Tartaglia
- Krembil Research Institute, 7989University Health Network Memory Clinic, Toronto, ON, Canada
| | - L Ruttan
- 7961University Health Network-Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - J Wither
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
| | - M Y Choi
- Cumming School of Medicine, 70401University of Calgary, Calgary, AB, Canada
| | - D Bonilla
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, 7938University of Toronto Lupus Clinic, Toronto, ON, Canada
| | - N Anderson
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, 7938University of Toronto Lupus Clinic, Toronto, ON, Canada
| | - S Appenzeller
- Department of Orthopaedics, Rheumatology and Traumatology, 7938University of Campinas, São Paulo, Brazil
| | - B Parker
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, 5292The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - P Katz
- 8785University of California, San Francisco, CA, USA
| | - D Beaton
- Institute for Work and Health, 7966University of Toronto, Toronto, ON, Canada
| | - R Green
- Krembil Research Institute, 7989University Health Network Memory Clinic, Toronto, ON, Canada
| | - I N Bruce
- Centre for Epidemiology Versus Arthritis, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, 5292The University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Z Touma
- Schroeder Arthritis Institute, Krembil Research Institute, 7989University Health Network, Toronto, ON, Canada
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, 7938University of Toronto Lupus Clinic, Toronto, ON, Canada
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Tayer-Shifman OE, Yuen K, Green R, Kakvan M, Katz P, Bingham KS, Diaz-Martinez JP, Ruttan L, Wither JE, Tartaglia MC, Su J, Bonilla D, Choi MY, Appenzeller S, Barraclough M, Beaton DE, Touma Z. Assessing the Utility of the Montreal Cognitive Assessment in Screening for Cognitive Impairment in Patients With Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2023; 75:569-577. [PMID: 35724303 DOI: 10.1002/acr.24971] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/24/2022] [Accepted: 06/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Screening for cognitive impairment (CI) in systemic lupus erythematosus (SLE) relies on the American College of Rheumatology (ACR) neuropsychological battery (NB). By studying the concurrent criterion validity, our goal was to assess the Montreal Cognitive Assessment (MoCA) as a screening tool for CI compared to the ACR-NB and to evaluate the added value of the MoCA to the Automated Neuropsychological Assessment Metrics (ANAM). METHODS A total of 285 adult SLE patients were administered the ACR-NB, MoCA, and ANAM. For the ACR-NB, patients were classified as having CI if there was a Z score of ≤-1.5 in ≥2 domains. The area under the curve (AUC) and sensitivities/specificities were determined. A discriminant function analysis was applied to assess the ability of the MoCA to differentiate between CI, undetermined CI, and non-CI patients. RESULTS CI was not accurately identified by the MoCA compared to the ACR-NB (AUC of 0.66). Sensitivity and specificity were poor at 50% and 69%, respectively, for the cutoff of 26, and 80% and 45%, respectively, for the cutoff of 28. The MoCA had a low ability to identify CI status. The addition of the MoCA to the ANAM led to improvement on the AUC by only 2.5%. CONCLUSION The MoCA does not have adequate concurrent criterion validity to accurately identify CI in patients with SLE. The low specificity of the MoCA may lead to overdiagnosis and concern among patients. Adding the MoCA to the ANAM does not substantially improve the accuracy of the ANAM. These results do not support using the MoCA as a screening tool for CI in patients with SLE.
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Affiliation(s)
- Oshrat E Tayer-Shifman
- Meir Medical Center, Kfar Saba, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kimberley Yuen
- Toronto Western Hospital and University Health Network, Toronto, and Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Robin Green
- University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Mahta Kakvan
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | | | - Kathleen S Bingham
- University Health Network Centre for Mental Health, Toronto, Ontario, Canada
| | - Juan Pablo Diaz-Martinez
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Lesley Ruttan
- University Health Network-Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Joan E Wither
- Schroeder Arthritis Institute and University Health Network, Toronto, Ontario, Canada
| | | | - Jiandong Su
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Dennisse Bonilla
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - May Y Choi
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Michelle Barraclough
- Toronto Western Hospital and Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | | | - Zahi Touma
- Toronto Western Hospital, Schroeder Arthritis Institute, University Health Network, and University of Toronto, Toronto, Ontario, Canada
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Yuen K, Beaton D, Bingham K, Katz P, Su J, Diaz Martinez JP, Tartaglia MC, Ruttan L, Wither JE, Kakvan M, Anderson N, Bonilla D, Choi MY, Fritzler MJ, Green R, Touma Z. Validation of the automated neuropsychological assessment metrics for assessing cognitive impairment in systemic lupus erythematosus. Lupus 2022; 31:45-54. [PMID: 34957878 PMCID: PMC8793300 DOI: 10.1177/09612033211062530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We previously demonstrated the utility of the Automated Neuropsychological Assessment Metrics (ANAM) for screening cognitive impairment (CI) in patients with systemic lupus erythematosus (SLE) and developed composite indices for interpreting ANAM results. Our objectives here were to provide further support for the ANAM's concurrent criterion validity against the American College of Rheumatology neuropsychological battery (ACR-NB), identify the most discriminatory subtests and scores of the ANAM for predicting CI, and provide a new approach to interpret ANAM results using Classification and Regression Tree (CART) analysis. METHODS 300 adult SLE patients completed an adapted ACR-NB and ANAM on the same day. As per objectives, six models were built using combinations of ANAM subtests and scores and submitted to CART analysis. Area under the curve (AUC) was calculated to evaluate the ANAM's criterion validity compared to the adapted ACR-NB; the most discriminatory ANAM subtests and scores in each model were selected, and performance of models with the highest AUCs were compared to our previous composite indices; decision trees were generated for models with the highest AUCs. RESULTS Two models had excellent AUCs of 86 and 89%. Eight most discriminatory ANAM subtests and scores were identified. Both models demonstrated higher AUCs against our previous composite indices. An adapted decision tree was created to simplify the interpretation of ANAM results. CONCLUSION We provide further validity evidence for the ANAM as a valid CI screening tool in SLE. The decision tree improves interpretation of ANAM results, enhancing clinical utility.
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Affiliation(s)
- Kimberley Yuen
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital Lupus Clinic, Toronto, ON, Canada
| | | | - Kathleen Bingham
- Toronto General Hospital, Centre for Mental Health, University Health Network, Toronto, ON, Canada
| | - Patricia Katz
- University of California at San Francisco, San Francisco, CA, United States
| | - Jiandong Su
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University of Toronto Lupus Clinic, Toronto, ON, Canada
| | - Juan Pablo Diaz Martinez
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University of Toronto Lupus Clinic, Toronto, ON, Canada
| | | | - Lesley Ruttan
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Joan E. Wither
- Schroeder Arthritis Institute, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Mahta Kakvan
- Toronto Western Hospital/Rheumatology, University Health Network, Toronto, ON, Canada
| | - Nicole Anderson
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Dennisse Bonilla
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - May Y. Choi
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Robin Green
- Toronto Rehabilitation Institute - University Centre, University Health Network, Toronto, ON, Canada
| | - Zahi Touma
- Internal Medicine, Division of Rheumatology, University of Toronto, Toronto, ON, Canada
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He JW, Diaz Martinez JP, Bingham K, Su J, Kakvan M, Tartaglia MC, Ruttan L, Beaton D, Wither J, Choi MY, Fritzler MJ, Anderson N, Bonilla D, Green R, Katz P, Touma Z. Insight into intraindividual variability across neuropsychological tests and its association with cognitive dysfunction in patients with lupus. Lupus Sci Med 2021; 8:8/1/e000511. [PMID: 34610995 PMCID: PMC8493902 DOI: 10.1136/lupus-2021-000511] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/03/2021] [Indexed: 11/16/2022]
Abstract
Objective Dispersion, or variability in an individual’s performance across multiple tasks at a single assessment visit, has been associated with cognitive dysfunction (CD) in many neurodegenerative and neurodevelopmental disorders. We aimed to compute a dispersion score using neuropsychological battery (NB) tests and determine its association with CD in patients with SLE. Methods CD was defined as a z-score of ≤−1.5 on ≥2 domains of the NB. To compute a type of dispersion score known as the intraindividual SD (ISD), the SD of age-adjusted and sex-adjusted z-scores was calculated for each visit in each patient. To estimate the association between ISD and cognitive status (CD and non-CD), we used multilevel logistic regression, adjusting for clinically important covariates. Results A total of 301 adult patients with SLE completed the NB at baseline, 187 of whom were reassessed at 6 months and 189 at 12 months. CD was observed in 35.2% of patients at baseline, 27.8% at 6 months and 28.0% at 12 months. Prior to covariate adjustment, the mean ISD for non-CD was 1.10±0.31 compared with 1.50±0.70 for CD. After adjusting for ethnicity, education, employment, socioeconomic status and anxiety/depression, there was a statistically significant association between ISD and CD (OR for one-unit increase in ISD: 13.56, 95% CI 4.80 to 38.31; OR for 1/10th-unit increase in ISD: 1.30, 95% CI 1.17 to 1.44). Findings were valid across multiple sensitivity analyses. Conclusion This is the first study to show that patients with SLE who were classified as having CD by the NB had more variability across the NB tests (ie, higher ISD score) compared with those who were not classified as having CD.
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Affiliation(s)
- Jennifer Wei He
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Juan Pablo Diaz Martinez
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Kathleen Bingham
- Psychiatry Department, Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Jiandong Su
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Mahta Kakvan
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Lesley Ruttan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Dorcas Beaton
- Institute for Work and Health, University of Toronto, Toronto, Ontario, Canada
| | - Joan Wither
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Krembil Neurosciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - May Y Choi
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Marvin J Fritzler
- Department of Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Nicole Anderson
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Dennisse Bonilla
- Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Robin Green
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Patricia Katz
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Zahi Touma
- Institute for Work and Health, University of Toronto, Toronto, Ontario, Canada .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Rheumatology, University Health Network, Toronto, Ontario, Canada
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Tayer‐Shifman OE, Green R, Beaton DE, Ruttan L, Wither JE, Tartaglia MC, Kakvan M, Lombardi S, Anderson N, Su J, Bonilla D, Zandy M, Choi MY, Fritzler MJ, Touma Z. Validity Evidence for the Use of Automated Neuropsychologic Assessment Metrics As a Screening Tool for Cognitive Impairment in Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 72:1809-1819. [DOI: 10.1002/acr.24096] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/15/2019] [Indexed: 12/26/2022]
Affiliation(s)
| | - Robin Green
- University Health Network–Toronto Rehabilitation Institute Toronto Ontario Canada
| | - Dorcas E. Beaton
- Institute for Work and Health and University of Toronto Toronto Ontario Canada
| | - Lesley Ruttan
- University Health Network–Toronto Rehabilitation Institute Toronto Ontario Canada
| | - Joan E. Wither
- University of Toronto Lupus Clinic and Toronto Western Hospital Toronto Ontario Canada
| | | | - Mahta Kakvan
- University of Toronto Lupus Clinic and Toronto Western Hospital Toronto Ontario Canada
| | - Sabrina Lombardi
- University Health Network–Toronto Rehabilitation Institute Toronto Ontario Canada
| | - Nicole Anderson
- University of Toronto Lupus Clinic and Toronto Western Hospital Toronto Ontario Canada
| | - Jiandong Su
- University of Toronto Lupus Clinic and Toronto Western Hospital Toronto Ontario Canada
| | - Dennisse Bonilla
- University of Toronto Lupus Clinic and Toronto Western Hospital Toronto Ontario Canada
| | - Moe Zandy
- University of Toronto Lupus Clinic and Toronto Western Hospital Toronto Ontario Canada
| | - May Y. Choi
- Cumming School of Medicine University of Calgary Calgary Alberta Canada
| | | | - Zahi Touma
- University of Toronto Lupus Clinic and Toronto Western Hospital Toronto Ontario Canada
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Kakvan M, Wong Kee You A, Adler S. Attentional Switching in Bilingual and Monolingual Infants: An Eye Movement Study. J Vis 2015. [DOI: 10.1167/15.12.1263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kakvan M, Garber AJ. An overview of the current status of islet cell transplantation as a treatment for diabetes mellitus. Islet cell transplantation, artificial pancreas, or genetic insulin synthesis offer possibilities for physiologic glucose regulation. R I Med J (1976) 1979; 62:361-6. [PMID: 115077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kakvan M, Martin RR. Modern concepts in the pathogenesis of rheumatic fever. R I Med J (1976) 1978; 61:23-6. [PMID: 345397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Kakvan M, Greenberg SD. Cigarette smoking and cancer of the lung: a review. R I Med J (1976) 1977; 60:588-91, 606. [PMID: 203017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Abstract
A simple, inexpensive, highly efficient disposable membrane oxygenator with low priming volume and a microporous membrane recently has become available. Animal and clinical investigations of its use have been most satisfactory, and clinical experience now has been extended to include 285 patients. Its primary advantage has been the ability to control oxygenation and carbon dioxide separately. Disadvantages have included the somewhat increased complexity of the system as compared with bubble oxygenator systems, the necessity of converting pumps for its use, and excessive condensation of water vapor in the gas phase of the oxygenator unless certain precautions are followed.
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Karlson KE, Murphy WR, Kakvan M, Anthony P, Cooper GN, Richardson PD, Galletti PM. Total cardiopulmonary bypass with a new microporous Teflon membrane oxygenator. Surgery 1974; 76:935-45. [PMID: 4547870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kakvan M, Wright JT. Criteria for surgery and choice of valve prostheses in patients with rheumatic heart disease. R I Med J (1974) 1974; 57:503-6, 517. [PMID: 4280614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Kakvan M. Physiological basis of rehabilitation in coronary heart disease. R I Med J (1974) 1974; 57:208-11 passim. [PMID: 4276868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Trudell LA, Friedman LI, Kakvan M, Galletti PM, Richardson PD. Evaluation of a disposable membrane oxygenator. Trans Am Soc Artif Intern Organs 1972; 18:538-45. [PMID: 4679910 DOI: 10.1097/00002480-197201000-00128] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kakvan M, Carriere S, Levy R, Gagnon E. Evaluation of collateral myocardial blood flow following long term implantation of the internal mammary artery in the dog. R I Med J 1971; 54:458-61. [PMID: 5286012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Kakvan M. Rehabilitation in coronary heart disease. R I Med J 1970; 53:429-32 passim. [PMID: 5273008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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