Positive Predictive Value of Sarcoidosis Identified in an Administrative Healthcare Registry: A Validation Study

Sarcoidosis in first- and second-generation immigrants: a cohort study of all adults 18 years of age and older in Sweden

BACKGROUND

There is a lack of studies on sarcoidosis among immigrants, which is of interest as there may be genetic and environmental characteristics affecting immigrants from certain countries. We aimed to study hazard ratios (HRs) of sarcoidosis in first- and second-generation immigrants, comparing them with native Swedes in the total adult Swedish population.

METHODS

We conducted a nationwide study of individuals ≥18 y of age. Sarcoidosis was defined as at least two registered diagnoses in the National Patient Register between 1 January 1998 and 31 December 2018. Cox regression analysis was used to estimate HRs with 99% confidence intervals (CIs) of first registration of sarcoidosis in first- and second-generation immigrants compared with native Swedes. The Cox regression models were stratified by sex and adjusted for age, comorbidities and sociodemographic characteristics.

RESULTS

In total, 6 175 251 were included in the first-generation study, with 12 617 cases of sarcoidosis, and 4 585 529 in the second-generation study, with 12 126 cases. The overall sarcoidosis risk was lower in foreign-born men (fully adjusted HR 0.63 [99% CI 0.57 to 0.69]) but not in foreign-born women (fully adjusted HR 0.98 [99% CI 0.90 to 1.06]). The overall risk was slightly lower in second-generation immigrants (HR 0.82 [99% CI 0.78 to 0.88]). Women from Asia exhibited a higher risk (HR 1.25 [99% CI 1.02 to 1.53)], while a potential trend was observed among women from Africa (HR 1.47 [99% CI 0.99 to 2.19]).

CONCLUSIONS

Sarcoidosis risk was lower in foreign-born men but not in women and also lower in second-generation immigrants.

Menopausal hormone therapy and risk of sarcoidosis: a population-based nested case-control study in Sweden

Sarcoidosis incidence peaks in women between 50 and 60 years old, which coincides with menopause, suggesting that certain sex hormones, mainly estrogen, may play a role in disease development. We investigated whether menopausal hormone therapy (MHT) was associated with sarcoidosis risk in women and whether the risk varied by treatment type. We performed a nested case-control study (2007-2020) including incident sarcoidosis cases from the Swedish National Patient Register (n = 2593) and matched (1:10) to general population controls (n = 20,003) on birth year, county, and living in Sweden at the time of sarcoidosis diagnosis. Dispensations of MHT were obtained from the Swedish Prescribed Drug Register before sarcoidosis diagnosis/matching. Adjusted odds ratios (aOR) of sarcoidosis were estimated using conditional logistic regression. Ever MHT use was associated with a 25% higher risk of sarcoidosis compared with never use (aOR 1.25, 95% CI 1.13-1.38). When MHT type and route of administration were considered together, systemic estrogen was associated with the highest risk of sarcoidosis (aOR 1.51, 95% CI 1.23-1.85), followed by local estrogen (aOR 1.25, 95% CI 1.11-1.42), while systemic estrogen-progestogen combined was associated with the lowest risk compared to never users (aOR 1.12, 95% CI 0.96-1.31). The aOR of sarcoidosis did not differ greatly by duration of MHT use. Our findings suggest that a history of MHT use is associated with increased risk of sarcoidosis, with women receiving estrogen administered systemically having the highest risk.

Long-Term Risk of VTE in Sarcoidosis: A Nationwide Cohort Study

BACKGROUND

Chronic inflammation is increasingly recognized as a risk factor for VTE, but unlike other inflammatory diseases including systemic lupus erythematosus and rheumatoid arthritis, data on the risk of VTE in patients with sarcoidosis are sparse.

RESEARCH QUESTION

Do patients with sarcoidosis have a higher long-term risk of VTE (pulmonary embolism or DVT, and each of these individually) compared with the background population?

STUDY DESIGN AND METHODS

Using Danish nationwide registries, patients aged ≥ 18 years with newly diagnosed sarcoidosis (two or more inpatient/outpatient visits, 1996-2020) without prior VTE were matched 1:4 by age, sex, and comorbidities with individuals from the background population. The primary outcome was VTE.

RESULTS

We included 14,742 patients with sarcoidosis and 58,968 matched individuals (median age, 44.7 years; 57.2% male). The median follow-up was 8.8 years. Absolute 10-year risks of outcomes for patients with sarcoidosis vs the background population were the following: VTE, 2.9% vs 1.6% (P < .0001), pulmonary embolism, 1.5% vs 0.7% (P < .0001), and DVT, 1.6% vs 1.0% (P < .0001), respectively. In multivariable Cox regression, sarcoidosis was associated with an increased rate of all outcomes in the first year after diagnosis (VTE: hazard ratio [HR], 4.94; 95% CI, 3.61-6.75) and after the first year (VTE: HR, 1.65; 95% CI, 1.45-1.87) compared with the background population. These associations persisted when excluding patients with a history of cancer and censoring patients with incident cancer during follow-up. Three-month mortality was not significantly different between patients with VTE with and without sarcoidosis (adjusted HR, 0.84; 95% CI, 0.61-1.15).

INTERPRETATION

In this nationwide cohort study, sarcoidosis was associated with a higher long-term risk of VTE compared with a matched background population.

Demographics, Cutaneous Manifestations, and Comorbidities Associated with Progressive Cutaneous Sarcoidosis: A Retrospective Cohort Study

Background: Sarcoidosis is a multisystem granulomatous disease with a wide variety of presentations and clinical courses. Cutaneous manifestations and comorbidities associated with sarcoid prognosis remain understudied. Methods: An EPIC query was run for patients age 18+ at the Johns Hopkins Hospital with a diagnosis of sarcoidosis of the skin according to the ICD-10-CM code D86.3. Data were obtained from a population-based sample of 240 patients from 2015 to 2020. Results: A total of 240 patients were included in the cohort study. The mean (SD) age was 43.76 (11.72) years, and 30% of participants were male; 76.25% of patients identified as black, 19.58% as white, and 4.17% as other. The average age of onset in remissive patients was significantly higher than progressive (47 ± 12 vs. 40 ± 10, p = 0.0005); 49% of black patients experienced progressive sarcoid compared to 32.6% of white patients (p = 0.028). Progressive disease was associated with the presence of lupus pernio (aOR = 3.29, 95% CI, 1.60-6.77) and at least one autoimmune comorbidity (aOR 6.831, 95% CI 1.819-11.843). Conclusions: When controlling for patient demographics, lupus pernio and the presence of at least one autoimmune condition were associated with progressive cutaneous sarcoidosis.

Epidemiology of Sarcoidosis in U.S. Veterans from 2003 to 2019

Rationale: United States veterans represent an important population to study sarcoidosis. Their unique history of environmental exposures, wide geographic distribution, and long-term enrollment in a single integrated healthcare system provides an unparalleled opportunity to understand the incidence, prevalence, and risk factors for sarcoidosis. Objectives: To determine the epidemiology, patient characteristics, geographic distribution, and associated risk factors of sarcoidosis among U.S. veterans. Methods: We used data from the Veterans Health Administration (VHA) electronic health record system between 2003 and 2019 to evaluate the annual incidence, prevalence, and geographic distribution of sarcoidosis (defined using the International Classification of Diseases codes). We used multivariate logistic regression to examine patient characteristics associated with sarcoidosis incidence. Results: Among more than 13 million veterans who received care through or paid for by the VHA, 23,747 (0.20%) incident diagnoses of sarcoidosis were identified. Compared with selected VHA control subjects using propensity score matching, veterans with sarcoidosis were more likely to be female (13.5% vs. 9.0%), of Black race (52.2% vs. 17.0%), and ever-tobacco users (74.2% vs. 64.5%). There was an increase in the annual incidence of sarcoidosis between 2004 and 2019 (from 38 to 52 cases/100,000 person-years) and the annual prevalence between 2003 and 2019 (from 79 to 141 cases/100,000 persons). In a multivariate logistic regression model, Black race (odds ratio [OR], 4.49; 95% confidence interval [CI], 4.33-4.65), female sex (OR, 1.64; 95% CI, 1.56-1.73), living in the Northeast compared with the western region (OR, 1.57; 95% CI, 1.48-1.67), history of tobacco use (OR, 1.36; 95% CI, 1.31-1.41), and serving in the Army, Air Force, or multiple branches compared with the Navy (OR, 1.08; 95% CI, 1.03-1.13; OR, 1.10; 95% CI, 1.04-1.17; OR, 1.27; 95% CI, 1.16-1.39, respectively) were significantly associated with incident sarcoidosis (P < 0.0001). Conclusions: The incidence and prevalence of sarcoidosis are higher among veterans than in the general population. Alongside traditionally recognized risk factors such as Black race and female sex, we found that a history of tobacco use within the Veterans Affairs population and serving in the Army, Air Force, or multiple service branches were associated with increased sarcoidosis risk.

Association between parental mental illness and autoimmune diseases in the offspring - A nationwide register-based cohort study in Sweden

Mental illness has been previously linked with autoimmune diseases, yet the associations between parental mental illness and offspring's risk of autoimmune diseases is largely unknown. We conducted a population-based cohort study of 2,192,490 Swedish children born between 1991 and 2011 and their parents to determine the associations between parental mental illness and risk of autoimmune diseases among the offspring. Time-dependent diagnoses of parental mental illness (psychosis, alcohol/drug misuse, depression, anxiety, eating disorders, personality disorders, attention deficit hyperactivity disorder, autism spectrum disorder) and offspring autoimmune diseases (type 1 diabetes (T1D), juvenile idiopathic arthritis (JIA), systemic lupus erythematosus, psoriasis, multiple sclerosis, inflammatory bowel disease (IBD), coeliac disease) were identified from inpatient/outpatient healthcare visits. Associations were measured by hazard ratios (HRs) adjusted for potential confounders. Overall, parental mental illness was associated with a small increase in risk of offspring's autoimmune diseases (HR 1.05, 95% CI 1.02-1.08). However, parental common mental disorder (anxiety/depression) was associated with higher risk of JIA, psoriasis, and T1D (HR T1D 1.11, 95% CI 1.01-1.22), while maternal psychosis with reduced risk of coeliac disease (HR 0.68, 95% CI 0.49-0.95) and paternal alcohol/drug misuse with reduced risk of IBD (HR 0.80, 95% CI 0.64-0.99). Maternal eating disorders were associated with a markedly increased risk for T1D (HR 1.41, 95% CI 1.05-1.89). Further studies are needed to confirm these findings and to understand underlying mechanisms. There is a need for greater clinical awareness about potential risk of JIA, psoriasis, and T1D among children of parents with common psychiatric morbidity.

Validation of Diagnostic Codes to Identify Carbon Monoxide Poisoning in Taiwan’s Claims Data

Purpose: Previous studies identified the study cohort or outcome of carbon monoxide poisoning (COP) by using the relevant disease diagnosis codes in secondary databases, but the validity of diagnosis codes of COP is unclear in such secondary databases. This study aimed to evaluate the accuracy of case definitions for COP using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes in Taiwan’s health insurance claims data.

Methods: We selected a 10% simple random sample from an original cohort of patients newly undergoing carboxyhemoglobin (COHb) testing under any clinical diagnosis at four Chang Gung Memorial Hospitals in Taiwan during 2011–2020. Two clinical doctors independently ascertained the COP diagnosis by reviewing the medical records as the reference standard. We estimated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of various case definitions (e.g., ICD-9-CM code, ICD-10-CM code and the uses of hyperbaric oxygen therapy) in the claims data.

Results: We randomly selected 557 cases from the original cohort of 5,571 cases newly receiving COHb test in the study hospitals. We found 90, 35, and 9 cases were true-positive, false-positive, and false-negative episodes of COP, respectively, among 278 cases with an ICD-9-CM code of 986. A further 111, 34, and 6 cases were true-positive, false-positive, and false-negative episodes of COP, respectively, among 279 cases with an ICD-10-CM code of T58. Using ICD-9-CM codes, the sensitivity, specificity, PPV and NPV for COP were 90.9, 80.4, 72, and 94.1%, respectively. Using ICD-10-CM codes they were 94.9, 79, 76.6, and 95.5%, respectively. PPV typically increased when COP was the primary diagnosis and could reach 100% if patients with ICD-CM code 986 or T58 also received hyperbaric oxygen therapy during hospitalization.

Conclusion: The COP-related ICD-CM codes alone did not accurately identify COP patients, but accuracy improved after including oxygen therapy data with the ICD-CM codes in Taiwan’s claims data.

Reproductive and hormonal risk factors for sarcoidosis: a nested case–control study

Background

Sarcoidosis incidence peaks in females around the fifth decade of life, which coincides with menopause, suggesting hormonal factors play a role in disease development. We investigated whether longer exposure to reproductive and hormonal factors is associated with reduced sarcoidosis risk.

Methods

We conducted a matched case–control study nested within the Mammography Screening Project. Incident sarcoidosis cases were identified via medical records and matched to controls on birth and questionnaire date (1:4). Information on hormonal factors was obtained through questionnaires prior to sarcoidosis diagnosis. Multilevel modelling was used to estimate adjusted odds ratios with 95% credible intervals (OR; 95% CI).

Results

In total, 32 sarcoidosis cases and 124 controls were included. Higher sarcoidosis odds were associated with older age at menarche (OR 1.19: 95% CI 0.92–1.55), natural menopause versus non-natural (OR 1.53: 95% CI 0.80–2.93), later age at first pregnancy (OR 1.11: 95% CI 0.76–1.63) and ever hormone replacement therapy (HRT) use (OR 1.40: 95% CI 0.76–2.59). Lower odds were associated with older age at menopause (OR 0.90: 95% CI 0.52–1.55), longer duration of oral contraceptive use (OR 0.70: 95% CI 0.45–1.07), longer duration of HRT use (OR 0.61: 95% CI 0.22–1.70), ever local estrogen therapy (LET) use (OR 0.83: 95% CI 0.34–2.04) and longer duration of LET use (OR 0.78: 95% CI 0.21–2.81). However, the CIs could not rule out null associations.

Conclusion

Given the inconsistency and modest magnitude in our estimates, and that the 95% credible intervals included one, it still remains unclear whether longer estrogen exposure is associated with reduced sarcoidosis risk.

Risk of acute myocardial infarction in sarcoidosis: A population-based cohort study from Sweden

Due to conflicting findings in previous studies, it remains unclear whether individuals with sarcoidosis are at a higher relative risk of acute myocardial infarction. In this cohort study, individuals with sarcoidosis and matched general population comparators were followed for acute myocardial infarction in Swedish nationwide registers. A small (20%) risk increase associated with sarcoidosis was identified, which did not markedly vary by age at diagnosis, sex, treatment status around diagnosis, and time since diagnosis. The highest relative risk (1.4) was observed in individuals who received immunosuppressant treatment around the time of sarcoidosis diagnosis. Future studies should examine the clinical characteristics of acute myocardial infarction in these patients and investigate whether early diagnostic or preventive interventions might be beneficial for these patients.

Risk and predictors of heart failure in sarcoidosis in a population-based cohort study from Sweden

OBJECTIVES

Previous studies showed a strong association between sarcoidosis and heart failure (HF) but did not consider risk stratification or risk factors to identify useful aetiological insights. We estimated overall and stratified HRs and identified risk factors for HF in sarcoidosis.

METHODS

Sarcoidosis cases were identified from the Swedish National Patient Register (NPR; ≥2 International Classification of Diseases-coded visits, 2003-2013) and matched to general population comparators. They were followed for HF in the NPR. Treated were cases who were dispensed ≥1 immunosuppressant ±3 months from the first sarcoidosis visit (2006-2013). Using Cox models, we estimated HRs adjusted for demographics and comorbidity and identified independent risk factors of HF together with their attributable fractions (AFs).

RESULTS

During follow-up, 204 of 8574 sarcoidosis cases and 721 of 84 192 comparators were diagnosed with HF (rate 2.2 vs 0.7/1000 person-years, respectively). The HR associated with sarcoidosis was 2.43 (95% CI 2.06 to 2.86) and did not vary by age, sex or treatment status. It was higher during the first 2 years after diagnosis (HR 3.7 vs 1.9) and in individuals without a history of ischaemic heart disease (IHD; HR 2.7 vs 1.7). Diabetes, atrial fibrillation and other arrhythmias were the strongest independent clinical predictors of HF (HR 2.5 each, 2-year AF 20%, 16% and 12%, respectively).

CONCLUSIONS

Although low, the HF rate was more than twofold increased in sarcoidosis compared with the general population, particularly right after diagnosis. IHD history cannot solely explain these risks, whereas ventricular arrhythmias indicating cardiac sarcoidosis appear to be a strong predictor of HF in sarcoidosis.