Epidemiology and impact of rheumatic disorders in the United States Hispanic population

Sarcoidosis among US Hispanics in a Nationwide Registry

BACKGROUND

Sarcoidosis has been well studied in multiple races and ethnic groups. However, there is a paucity of data that describes sarcoidosis in Hispanics. We aimed to determine the prevalence of Hispanic ethnicity, clinical characteristics and impact of sarcoidosis among Hispanics from a US based national registry.

METHODS

We conducted a national registry-based study investigating 3835 respondents to the Sarcoidosis Advanced Registry for Cures questionnaire. This registry is a web-based, self-reported questionnaire that provides data related to demographics, diagnostics, organ involvement, treatment modalities, and the physical and psychosocial impact of sarcoidosis. We compared Hispanic patients to non-Hispanics. We performed multivariate logistic regression analysis adjusting for age, gender, education, income and insurance status and looked at the association between Hispanic ethnicity with depression, chronic pain syndrome, chronic fatigue syndrome, impact on family finances, employment-based disability and job termination.

RESULTS

Nine percent of the patients reported a Hispanic ethnicity and the majority of these patients self-identified as white women. The most common organs involved were the lungs (74.9%), central lymph nodes (53.8%), and peripheral lymph nodes (37.1%). Hispanics reported more peripheral nerves and peripheral lymph nodes involvement than non-Hispanics. Hispanics experienced more depression, sleep apnea, and chronic pain syndrome than non-Hispanics. The use of mobility assistive devices was more common among Hispanics, as well as employment-based disability, and disease-related job termination compared to non-Hispanics. The majority of Hispanics reported significantly more pain that interfered with the enjoyment of life than non-Hispanics. On multivariate logistic regression analysis, Hispanic ethnicity was associated with depression (adjusted odds ratio (aOR) = 1.5; 95% CI: 1.01-2.2), chronic pain syndrome (aOR = 1.7; 1.1-2.6), job termination due to sarcoidosis (aOR = 1.7; 1.1-2.7) and higher impact on family finances (aOR = 1.7; 1.1-2.5).

CONCLUSION

The clinical presentation of sarcoidosis in Hispanic patients differs from that in non-Hispanic patients living in the United States. These differences should be considered when managing Hispanic patients with sarcoidosis. We encourage more studies that investigate phenotyping among Hispanics with sarcoidosis.

Orthopedic Surgery in Rheumatoid Arthritis: Results from the Spanish National Registry of Hospitalized Patients over 17 Years

OBJECTIVE

To analyze the trend of orthopedic surgery (OS) rates on patients with rheumatoid arthritis (RA).

METHODS

Retrospective observational study based on information provided by the Spanish National System of Hospital Data Surveillance. All hospitalizations of patients with RA for orthopedic surgery [total hip arthroplasty (THA), total knee arthroplasty (TKA), arthrodesis, and upper limb arthroplasty (ULA)] during 1999-2015 were analyzed. The age-adjusted rate was calculated. Generalized linear models were used for trend analysis.

RESULTS

There were 21,088 OS in patients over 20 years of age (77.9% women). OS rate adjusted by age was 754.63/100,000 RA patients/year (women 707.4, men 861.1). Neither an increasing nor a decreasing trend was noted for the total OS. However, trend and age interacted, so in the age ranges 20-40 years and 40-60 years, an annual reduction of 2.69% and 2.97%, respectively, was noted. In the age ranges over 80 years and 60-80 years, we noted an annual increase of 5.40% and 1.09%, respectively. The average age at time of OS increased 5.5 years during the period analyzed. For specific surgeries, a global annual reduction was noted in rates for arthrodesis. In THA, there was an annual reduction in patients under 80 years. In TKA and ULA, there was an annual reduction in patients under 60 years.

CONCLUSION

Although the overall OS rate has not changed, there is a decrease in the rate of arthrodesis at all ages, THA in patients under 80 years of age, as well as TKA and ULA in patients under 60 years of age.

The global burden of SLE: prevalence, health disparities and socioeconomic impact

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that can potentially lead to serious organ complications and even death. Its global burden - in terms of incidence and prevalence, differential impact on populations, economic costs and capacity to compromise health-related quality of life - remains incompletely understood. The reported worldwide incidence and prevalence of SLE vary considerably; this variation is probably attributable to a variety of factors, including ethnic and geographic differences in the populations being studied, the definition of SLE applied, and the methods of case identification. Despite the heterogeneous nature of the disease, distinct patterns of disease presentation, severity and course can often be related to differences in ethnicity, income level, education, health insurance status, level of social support and medication compliance, as well as environmental and occupational factors. Given the potential for the disease to cause such severe and widespread organ damage, not only are the attendant direct costs high, but these costs are sometimes exceeded by indirect costs owing to loss of economic productivity. As an intangible cost, patients with SLE are, not surprisingly, likely to endure considerably reduced health-related quality of life.

Evaluation of the association between Hispanic ethnicity and disease activity and severity in a large cohort of patients with juvenile idiopathic arthritis

To examine the association between ethnicity and disease activity in patients with juvenile idiopathic arthritis (JIA), and to determine the association of ethnicity with disease severity and disability in this population. CARRAnet, a US database containing information (collected between May 2010 and June 2011) on almost 3,000 subjects with JIA, was used. Demographic variables were compared between Hispanic patients and non-Hispanic patients. Mann-Whitney and chi-square tests were used to compare indicators of disease activity, as well as imaging evidence of joint damage, and Childhood Health Assessment Questionnaire (CHAQ) scores between ethnicities. Two linear regression models were used to determine the association of ethnicity with number of active joints in JIA, and the association between ethnicity and disability (CHAQ scores). A total of 2,704 patients with JIA (277 Hispanic; 2,427 non-Hispanic) were included. Income and health insurance coverage were higher in non-Hispanics. RF-positive polyarticular JIA, positive RF and anti-CCP, as well as use of systemic steroids were more frequent in Hispanics. Imaging evidence of joint damage was present in 32 % of the Hispanic patients compared to 24 % of the non-Hispanic patients (p = 0.008). In multivariate linear regression analyses, the number of active joints was significantly higher in Hispanics than in non-Hispanics (p = 0.03), as well as CHAQ scores (p = 0.003), after adjusting for confounders. Hispanic patients with JIA had higher disease activity than non-Hispanic patients, as well as higher disease severity and disability. Since ethnicity influences disease activity, severity, and disability, different management and treatment plans should be planned accordingly.

Patients' and community leaders' perceptions regarding conducting health behavior research in a diverse, urban clinic specializing in rheumatic diseases

BACKGROUND

Disparities in the incidence, prevalence, severity, care, and outcomes for rheumatic diseases exist among racial and ethnic groups compared with White Americans.

OBJECTIVE

This paper describes a community-based participatory research (CBPR) approach engaging researchers, community leaders, and patients in purposeful dialogues related to the implementation of health behavior research in an urban rheumatic disease clinic.

METHODS

Seven focused discussions were led in either English or Spanish. Discussions were audiotaped and transcribed verbatim.

RESULTS

Six community leaders and nine patients participated in the seven scheduled focused discussions. Transcripts uncovered five major themes that assisted with study design: trust, patient-provider relationship, study implementation suggestions, decreased functional capacity, and access to healthcare.

CONCLUSIONS

Engaging community partners and patients in informal and formal discussions from early phases of research design through implementation, followed by systematic application of these insights, may serve to accelerate the potential for translation from findings into improved clinical practice and optimal outcomes.

The impact of rural residency on the expression and outcome of systemic lupus erythematosus: data from a multiethnic Latin American cohort

OBJECTIVE

The objective of this paper is to examine the role of place of residency in the expression and outcomes of systemic lupus erythematosus (SLE) in a multi-ethnic Latin American cohort.

PATIENTS AND METHODS

SLE patients (< two years of diagnosis) from 34 centers constitute this cohort. Residency was dichotomized into rural and urban, cut-off: 10,000 inhabitants. Socio-demographic, clinical/laboratory and mortality rates were compared between them using descriptive tests. The influence of place of residency on disease activity at diagnosis and renal disease was examined by multivariable regression analyses.

RESULTS

Of 1426 patients, 122 (8.6%) were rural residents. Their median ages (onset, diagnosis) were 23.5 and 25.5 years; 85 (69.7%) patients were Mestizos, 28 (22.9%) Caucasians and 9 (7.4%) were African-Latin Americans. Rural residents were more frequently younger at diagnosis, Mestizo and uninsured; they also had fewer years of education and lower socioeconomic status, exhibited hypertension and renal disease more frequently, and had higher levels of disease activity at diagnosis; they used methotrexate, cyclophosphamide pulses and hemodialysis more frequently than urban patients. Disease activity over time, renal damage, overall damage and the proportion of deceased patients were comparable in rural and urban patients. In multivariable analyses, rural residency was associated with high levels of disease activity at diagnosis (OR 1.65, 95% CI 1.06-2.57) and renal disease occurrence (OR 1.77, 95% CI 1.00-3.11).

CONCLUSIONS

Rural residency associates with Mestizo ethnicity, lower socioeconomic status and renal disease occurrence. It also plays a role in disease activity at diagnosis and kidney involvement but not on the other end-points examined.

Arthritic pain among Latinos: results from a community-based survey

OBJECTIVE

To examine factors associated with pain among Latinos with arthritis, identify common coping strategies and potentially effective interventions, and determine whether pain levels affect the level of interest in potentially useful programs.

METHODS

Using a convenience sampling approach and a combination of face-to-face and telephone surveys, 588 Latino adults in Oregon with arthritis were interviewed. The intensity of pain during a typical day was assessed using a scale ranging from 0 (no pain) to 10 (worst pain). A score of >or=7 was defined as severe pain.

RESULTS

More than 60% of Latinos reported severe pain. Results from an ordinary least square regression indicated that among Latinos with arthritis, women, those with lower levels of education, and those reporting poor or fair self-rated health and functional limitations had higher levels of pain, after controlling for confounders. Those with severe pain were more likely than those with lower levels of pain to use over the counter medicine and home remedies to manage their arthritis. In addition, Latinos with greater pain were more likely to be interested in arthritis management programs.

CONCLUSION

These findings have important implications for public health policy. The strong interest of Latinos in various arthritis and joint pain management programs could prove to be an important avenue for supporting a population with high levels of arthritic pain and lack of health insurance. These pain management programs are all the more appealing, given the availability of a number of evidence-based, low-cost interventions.

Rheumatoid arthritis: Disease or syndrome?

Rheumatoid arthritis (RA) has been described in the medical literature for over two hundred years, but its etiology remains unknown. RA displays phenotypic heterogeneity, and it is a relatively prevalent clinical entity: it affects approximately 1% of the population, resulting in enormous pathologic sequelae. Earlier studies targeting the cause(s) of RA suggested potential infectious involvement, whereas more recent reports have focused on a genetic origin of the disease. However, neither infection nor genetics, nor any other single factor is currently accepted as causative of RA. In this article we review studies relating to the etiology of RA, and those of several related matters, and we conclude that the literature indeed does provide insight into the causes underlying the initiation of RA pathogenesis. Briefly, given the remarkable phenotypic variation of RA, especially in its early stages, as well as a number of other characteristics of the condition, we contend that RA is not a discrete clinical entity with a single etiological source. Rather, we argue that it represents a common clinical endpoint for various starting points, each of which is largely guided by as yet poorly understood aspects of the genetic background of the affected individual. Adoption of this alternative view of the origin of RA will have significant consequences for future research and for development of new therapeutic interventions for this burdensome condition.

Admixture in Hispanic Americans: its impact on ITGAM association and implications for admixture mapping in SLE

Systemic Lupus Erythematosus (SLE) disproportionately affects minorities, such as Hispanic-Americans. Prevalence of SLE is 3–5 times higher in Hispanic Americans (HA) than European derived populations, and have more active disease at the time of diagnosis, with more serious organ system involvement. HA is an admixed population, it is possible that there is an effect of admixture on the relative risk of disease. This admixture can create substantial increase of linkage disequilibrium (LD) in both magnitude and range, which can provide a unique opportunity for admixture mapping. Main objectives of this study are to (a) estimate hidden population structure in HA individuals; (b) estimate individual ancestry proportions and its impact on SLE risk; (c) assess impact of admixture on ITGAM association, a recently identified SLE susceptibility gene; and (d) estimate power of admixture mapping in HA. Our dataset contained 1,125 individuals, of whom 884 (657 SLE cases and 227 controls) were self classified as HA. Using 107 unlinked ancestry informative markers (AIMs) we estimated hidden population structure and individual ancestry in HA. Out of 5,671 possible pair-wise LD, 54% were statistically significant, indicating recent population admixture. The best fitted model for HA was a four population model with average ancestry of European (48%), American-Indian (40%), African (8%) and a fourth population (4%) with unknown ancestry. We also identified significant higher risk associated with American-Indian ancestry (OR=4.84, P=0.0001, 95%CI=2.14—10.95) on overall SLE. We showed that ITGAM is associated as a risk factor for SLE (OR= 2.06, P=8.74×10⁻⁵, 95%CI=1.44–2.97). This association is not affected by population substructure or admixture. We have demonstrated that HA have great potential and are an 3 appropriate population for admixture mapping. As expected, the case-only design is more powerful than case-control design, for any given admixture proportion or ancestry risk ratio.

Health disparities among Latinas aging with disabilities

Latinas with disabilities report greater levels of disablement than non-Hispanic, White women with disabilities. Over the life course, Latinas experience increased numbers of functional limitations, more difficulties with activities of daily living, and more unemployment due to impairments. The reasons for this health disparity are unclear. The purpose of this article is to explore the empirical evidence surrounding health disparities in disablement among Mexican American women. From this exploration, recommendations are made, including moving beyond the correlational documentation of disparities, to building a knowledge base that provides theoretical reasons for disparities amenable to intervention.

Relaxation and guided imagery in Hispanic persons diagnosed with fibromyalgia: a pilot study

Fibromyalgia (FM) is a chronic pain disorder affecting 2% of the population in the United States. Another 16 million Hispanics suffer from generically identified rheumatic diseases that likely include FM. Because there are few reported studies of Hispanics with FM, a pilot study using a repeated-measures pretest-posttest design investigated the effects of a 10-week mind-body intervention (visual imagery with relaxation) on symptom management. The change in means from baseline to week 10 demonstrated improvement in self-efficacy for managing pain and other symptoms and functional status. Visual imagery with relaxation is a mind-body intervention that may be used for symptom management in this population.

Prevalence and correlates of arthritis-attributable work limitation in the US population among persons ages 18-64: 2002 National Health Interview Survey Data

OBJECTIVE

To estimate the national prevalence of arthritis-attributable work limitation (AAWL) among persons ages 18-64 with doctor-diagnosed arthritis and examine correlates of AAWL.

METHODS

Using the 2002 National Health Interview Survey, we estimated the prevalence of AAWL (limited in whether individuals work, the type of work they do, or the amount of work they do) and correlates of AAWL in univariable and multivariable-adjusted logistic regression analyses. Survey data were analyzed in SAS and SUDAAN to account for the complex sample design.

RESULTS

A total of 5.3% of all US adults ages 18-64 reported AAWL; in this age group, AAWL is reported by approximately 30% of those who report arthritis. The prevalence of AAWL was highest among people ages 45-64 years (10.2%), women (6.3%), non-Hispanic blacks (7.7%), people with less than a high school education (8.6%), and those with an annual household income <$20,000 (12.6%). AAWL was substantially increased among people with arthritis-attributable activity limitations (multivariable-adjusted odds ratio [OR] 9.1, 95% confidence interval [95% CI] 7.1-11.6). The multivariable-adjusted likelihood of AAWL was moderately higher among non-Hispanic blacks (OR 1.6, 95% CI 1.2-2.3), Hispanics (OR 1.8, 95% CI 1.2-2.6), and people with high levels of functional/social/leisure limitations (OR 1.8, 95% CI 1.4-2.3) and was decreased among those with a college education (OR 0.6, 95% CI 0.4-0.8).

CONCLUSION

AAWL is highly prevalent, affecting millions of Americans and one-third of adults with doctor-diagnosed arthritis. Findings suggest the need for more targeted research to better understand the natural history, success of interventions, and effects of policy on AAWL. Public health interventions, including self-management education programs, may be effective in countering AAWL.

Health status, activity limitations, and disability in work and housework among Latinos and non-Latinos with arthritis: an analysis of national data

OBJECTIVE

To document disparities in health status, activity limitations, and disability in work and housework between Latinos and non-Latino whites with arthritis. We examined whether sociodemographic factors (age, income, and education) account for the disparities between the ethnic groups, and whether comorbid conditions, disease duration, health care utilization, and functional abilities predict health status, activity limitations, and work and housework disability after controlling for sociodemographic variables.

METHODS

We analyzed data from the Condition file of the 1994 National Health Interview Survey on Disability, Phase I.

RESULTS

The risk of worse health, activity limitations, and work and housework disability was >2 times greater among Latinos compared with non-Latino whites. In the regression models accounting for potential confounders, Latino ethnicity remained significantly associated with poorer health status, but not activity limitations or disability in work or housekeeping. Of the socioeconomic status variables, education had a significant protective effect on work disability and health status. Comorbid conditions and health care utilization increased the likelihood of worse health, activity limitations, and work disability. Limitations in physical function were associated with poorer health and disability in work and homemaking.

CONCLUSION

Social status differences between Latinos and non-Latinos may account for disparities in activity limitations and disability in work and housework. Education may provide various health benefits, including access to a range of occupations that do not require physical demands. The findings help to address the great gap in knowledge concerning factors related to the health and disability status of Latinos with arthritis.

Comparison of AIMS2-SF, WOMAC, x-ray and a global physician assessment in order to approach quality of life in patients suffering from osteoarthritis

Background

Chronic diseases like osteoarthritis (OA) substantially affect different dimensions of quality of life (QoL). The aim of the study was to reveal possible factors which mainly influence general practitioners (GPs) assessment of patients' QoL.

Methods

220 primary care patients with OA of the knee or the hip treated by their general practitioner for at least one year were included. All GPs were asked to assess patients' QoL based on the patients' history, actual examination and existing x-rays by means of a visual analog scale (VAS scale), resulting in values ranging from 0 to 10. Patients were asked to complete the McMaster Universities Osteoarthritis Index (WOMAC) and the Arthritis Impact Measurement Scale2 Short Form (AIMS2-SF) questionnaire.

Results

Significant correlations were revealed between "GP assessment" and the AIMS2-SF scales "physical" (rho = 0.495) and "symptom" (rho = 0.598) as well as to the "pain" scale of the WOMAC (rho = 0.557). A multivariate ordinal regression analysis revealed only the AIMS2-SF "symptom" scale (coefficient beta = 0.2588; p = 0.0267) and the x-ray grading according to Kellgren and Lawrence as significant influence variables (beta = 0.6395; p = 0.0004).

Conclusion

The results of the present study suggest that physicians' assessment of patients' QoL is mainly dominated by physical factors, namely pain and severity of x-ray findings. Our results suggest that socioeconomic and psychosocial factors, which are known to have substantial impact on QoL, are underestimated or missed. Moreover, the overestimation of x-ray findings, which are known to be less correlated to QoL, may cause over-treatment while important and promising targets to increase patients' QoL are missed.

Differential effect of obesity on bone mineral density in White, Hispanic and African American women: a cross sectional study

Osteoporosis is a major public health problem with low bone mass affecting nearly half the women aged 50 years or older. Evidence from various studies has shown that higher body mass index (BMI) is a protective factor for bone mineral density (BMD). Most of the evidence, however, is from studies with Caucasian women and it is unclear to what extent ethnicity plays a role in modifying the effect of BMI on BMD.

A cross sectional study was performed in which records of postmenopausal women who presented for screening for osteoporosis at 2 urban medical centres were reviewed. Using logistic regression, we examined the interaction of race and BMI after adjusting for age, family history of osteoporosis, maternal fracture, smoking, and sedentary lifestyle on BMD. Low BMD was defined as T-score at the lumbar spine < -1.

Among 3,206 patients identified, the mean age of the study population was 58.3 ± 0.24 (Years ± SEM) and the BMI was 30.6 kg/m². 2,417 (75.4%) were African Americans (AA), 441(13.6%) were Whites and 348 (10.9%) were Hispanics. The AA women had lower odds of having low BMD compared to Whites [Odds ratio (OR) = 0.079 (0.03–0.24) (95% CI), p < 0.01]. The odds ratio of low BMD was not statistically significant between White and Hispanic women. We examined the interaction between race and BMD. For White women; as the BMI increases by unity, the odds of low BMD decreases [OR = 0.9 (0.87–0.94), p < 0.01; for every unit increase in BMI]. AA women had slightly but significantly higher odds of low BMD compared to Whites [OR 1.015 (1.007–1.14), p <0.01 for every unit increase in BMI]. This effect was not observed when Hispanic women were compared to Whites.

There is thus a race-dependent effect of BMI on BMD. With each unit increase in BMI, BMD increases for White women, while a slight but significant decrease in BMD occurs in African American women.

Systemic lupus erythematosus in a multiethnic US cohort (LUMINA): XXII. Predictors of time to the occurrence of initial damage

OBJECTIVE

To examine the factors predisposing to initial damage in patients in the LUMINA (lupus in minorities: nature versus nurture) cohort, a multiethnic cohort of patients with systemic lupus erythematosus (SLE) in the US.

METHODS

One hundred fifty-eight LUMINA patients with no damage at baseline (time 0) according to the Systemic Lupus International Collaborating Clinics Damage Index (SDI) and with disease duration > 6 months were followed up for a median of 24 months (range 5-112 months). Damage was assessed from time 0 to the last visit. Predictors of time to initial damage were examined by univariable and multivariable Cox proportional hazard regression models. Results were reported as hazard ratios (HRs); HR values > or = 1 indicated a shorter time to initial damage, and values < 1 indicated a longer time.

RESULTS

Initial damage occurred in 54 patients (34%), of whom 21 were Hispanics from Texas (39%), 2 were Hispanics from Puerto Rico (4%), 21 were African Americans (39%), and 10 were Caucasians (19%). The most frequently observed initially involved SDI domains (and items) were as follows: renal (primarily proteinuria) in Hispanics from Texas and African Americans, integument (primarily scarring alopecia) in Hispanics from Puerto Rico, and ocular (primarily cataracts) in Caucasians. By multivariable analyses, independent predictors of a shorter time to initial damage were Hispanic ethnicity from Texas (HR 2.11, 95% confidence interval [95% CI] 1.15-3.88), greater disease activity according to the Systemic Lupus Activity Measure (HR 1.09, 95% CI 1.04-1.15), the occurrence of thrombotic events in visceral and/or peripheral veins or arteries (HR 7.66, 95% CI 2.13-27.51), and prednisone at a dosage of < 10 mg/day (HR 2.53, 95% CI 1.15-5.55). Prednisone at a dosage of 10-30 mg/day was found to be protective against the occurrence of initial damage (HR 0.46, 95% CI 0.22-0.96).

CONCLUSION

Given that damage is a predictor of further damage, identifying the factors that may herald the occurrence of initial damage has very practical implications for the management of patients with SLE. These results need to be considered when evaluating therapies for SLE.

Ethnic disparities in patients with systemic lupus erythematosus

Ethnic disparities in health care have been historically well documented, but their causes still remain poorly explained. In the US, ethnic minorities have a higher incidence and prevalence of systemic lupus erythematosus and also experience less favorable outcomes when compared with the Caucasian majority. These discrepancies can be explained, at least in part, by genetic-related ethnic factors; however, nongenetic factors emerging from differences in socioeconomic status and related individual social (poverty, limited access to quality health care) and cultural characteristics (inadequate health belief patterns, distrust in medical institutions) are also likely to contribute to these discrepancies. A comprehensive recognition of current unfavorable, but modifiable, circumstances will provide the framework to develop strategic approaches toward eliminating existent disparities in health, including those occurring in patients with systemic lupus erythematosus.

Abnormalities of Bone Mineral Density and Bone Metabolism in Venezuelan Patients with Rheumatoid Arthritis

Patients with rheumatoid arthritis (RA) are at increased risk for osteoporosis and bone fractures. To our knowledge, the frequency of osteopenia and osteoporosis in patients with RA from Latin America has not been established. In this study, we have examined the bone mineral density (BMD) by dual-energy x-ray absorptiometry, as well as biochemical markers of bone metabolism, in a population of 85 Venezuelan RA patients. Twenty-seven patients (29.4%) fulfilled the World Health Organization's (WHO) criteria for either trabecular osteopenia or osteoporosis compared with 10 healthy controls (8.1%; odds ratio [OR] = 3.25; P = 0.004). In addition, 30 patients (26.4%) showed cortical osteopenia or osteoporosis compared with 5 healthy controls (4.0%; OR = 8.18; P < 0.00001). Past or concurrent use of prednisone or methotrexate was not related to decreased BMD. Rheumatoid patients showed increased serum levels of osteocalcin (P = 0.002) and 24-hour urine excretion of N-telopeptide cross-links (P = 0.03). The bone marker profiles suggest an increased bone turnover during the premenopausal stage in these patients. After menopause, a resorptive pattern seems to predominate, leading to accelerated bone mass loss in RA patients. In conclusion, Venezuelan female patients with RA may be at increased risk for osteopenia or osteoporosis, particularly after menopause. Our study supports the initiation of antiresorptive medication in Latin American premenopausal patients with RA, as in other ethnic groups, to diminish the risk of osteoporosis in the postmenopausal stage.

Osteoporosis and quality of life psychosocial outcomes and interventions for individual patients

Despite the substantial psychosocial impact of osteoporosis, little research has evolved in this area. Early reports conceptualized these nonskeletal problems as psychosocial in nature, but more recent investigations focus on health-related quality of life (HRQOL). Multiple HRQOL instruments have been designed to measure this construct in people with osteoporosis, and each has its strengths and weaknesses. Unfortunately, so much investigative energy has been spent on psychometric testing that these instruments have not been put to work efficiently to identify problem areas in HRQOL. It is from such results that interventions to improve HRQOL will occur.

Epidemiology of systemic lupus erythematosus

Several recent studies have suggested that the incidence of systemic lupus erythematosus (SLE) is increasing. The female to male ratio varies from 4.3 to 13.6. SLE is more common in African-Americans, African-Caribbeans, and Asians, than in Caucasians. The age at diagnosis is younger in African-Americans than in Caucasians. Improvement in survival levelled off in the 1980s; 20-year survival is only 53-61%.

Disparity in total hip replacement affecting Hispanic Medicare beneficiaries

OBJECTIVE

To compare the utilization of total hip replacement (THR) between Hispanic persons and non-Hispanic persons in a sample with health insurance.

RESEARCH DESIGN

Case-control study using Medicare claims data.

PATIENTS

The cases were Medicare beneficiaries from Arizona, Illinois, New Mexico, or Texas who underwent a primary THR. The controls were Medicare beneficiaries who did not receive a THR, matched by age, sex, and county of residence.

MEASURES

Beneficiary surnames and the race indicator in Medicare records were used to classify beneficiaries' probability of being Hispanic. Conditional logistic regression was used to estimate the odds of receiving of THR, adjusting for Medicaid eligibility.

RESULTS

Six thousand four hundred thirty-seven recipients of a primary THR were matched to 12,874 controls. According to the Medicare race indicator, 1% of recipients of THR and 3.3% of controls were Hispanic (P < or =0.001). The odds of THR decreased as the probability of Hispanic ethnicity increased, from an odds ratio (OR) of 1.00 among beneficiaries with non-Hispanic surnames, to an OR of 0.36 among those with heavily Hispanic surnames (95% CI, 0.31, 0.43). Poverty, as reflected by eligibility for Medicaid, did not modify the low odds of THR among Hispanic persons (OR, 0.25 among Medicaid-eligible Hispanic persons; 95% CI, 0.19, 0.33; and OR, 0.30 among Hispanic persons not Medicaid eligible; 95% CI, 0.24, 0.38).

CONCLUSION

Hispanic persons with Medicare receive THR at lower rates than do non-Hispanic persons. Because Medicare covers THR, our findings suggest that under utilization of THR by Hispanic persons cannot be attributed to lack of health insurance alone.

Can morbidity and mortality of SLE be improved?

Systemic lupus erythematosus (SLE) is the second most common autoimmune disorder (after thyroid disease) in women of childbearing age. Lupus is increasingly being recognized throughout the world's population. The incidence and prevalence of SLE varies among racial and ethnic groups. Lupus patient survival has significantly improved over the past five decades, but a three- to fivefold increased risk of death remains compared with the general population. As lupus patients survive longer, these individuals face a range of complications from the disease itself or consequent to its treatment. Emerging data from epidemiological studies underscore the importance of incorporating race and ethnicity in understanding the risk factors leading to the significant burden of mortality and morbidity associated with this disease. This chapter describes the epidemiology of lupus with a focus on racial and ethnic differences, reviews the mortality associated with the disease, discusses selected complications associated with morbidity related to the disease and highlights areas where we can improve mortality and morbidity.