Quality of life in paediatric lupus

Experiences and Perspectives of Children and Young People Living with Childhood-Onset Systemic Lupus Erythematosus-An Integrative Review

Childhood-onset systemic lupus erythematosus (cSLE) impacts the daily life of children and young people. This study aimed to describe the experiences and perspectives of children and young people living with cSLE. An integrative review guided by Whittemore and Knafl was conducted. Extant empirical research published in peer-reviewed journals from 2000 to 2021 on children's self-reported experiences living with cSLE was identified from Scopus, CINAHL, Medline via PubMed, and PsycINFO via Ovid databases. Nineteen studies involving over 1400 participants were included. Four themes and fourteen sub-themes were identified: (1) challenging symptoms (disruptions to life and altered self, severity, fatigue, depression, and anxiety), (2) medicines and side effects (dreaded steroids, conflicting feelings, and medication adherence), (3) complicated life (school sports and social, giving things up, lack of understanding, and quality of life) and (4) ways of coping (family and friends, relationships with health providers, and maintaining positivity). While cSLE shares many similarities with adult-onset SLE, awareness of differences in experiences and perceptions of children and young people is crucial. The significant psychological and social impact of the disease and its treatments necessitates a comprehensive, holistic approach to managing cSLE that considers the unique needs of youth.

Diagnostic Delays and Psychosocial Outcomes of Childhood-Onset Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that manifests in affected individuals with a variety of clinical features and involves multiple organs. Despite recent advances over the past decades, higher morbidity and mortality have been reported by studies in patients with childhood-onset systemic lupus erythematosus (cSLE) compared to patients with adult-onset. The interplay of several factors can cause diagnostic delays resulting in worse disease activity, multiple organ damage, increased risk of hospitalization, and management with aggressive treatment. Significant factors include demographic, clinical, and socioeconomic characteristics of patients with cSLE. Moreover, despite recent advances in lupus treatment, prolonged disease duration in these young patients can result in debilitating psychosocial outcomes and can significantly impact their health-related and general quality of life (QOL). Important domains affected include patient self-esteem, education, employment, healthcare utilization, and mental health. In this review, we examined the barriers that lead to a delay in diagnosing lupus in the pediatric population and addressed cSLE morbimortality and its long-term impact on patient health-related and general QOL.

'It is good to have a target in mind': qualitative views of patients and parents informing a treat to target clinical trial in juvenile-onset systemic lupus erythematosus

OBJECTIVE

We sought to explore patient and parental views on treatment targets, outcome measures and study designs being considered for a future JSLE treat-to-target (T2T) study.

METHODS

We conducted topic-guided, semistructured interviews with JSLE patients and parents and analysed the audio recorded interviews using thematic approaches.

RESULTS

Patients and parents differed regarding symptoms they felt would be tolerable, representing 'low disease activity'. Patients often classed symptoms that they had previously experienced, were 'invisible' or had minimal disruption on their life as signs of low disease activity. Parents were more accepting of visible signs but were concerned about potential organ involvement and symptom severity. Overall, patients and parents preferred that children were entirely asymptomatic, with no ongoing treatment side effects. They regarded fatigue as particularly challenging, requiring proper monitoring using a fatigue patient-reported outcome measure. Most families felt that reducing corticosteroids would also be a good treatment target. Overall, families liked the concept of T2T, commenting that it could help to improve disease control, help structure treatment and improve communication with clinicians and treatment compliance. They were concerned that T2T might increase the frequency of hospital visits, thus impacting upon schooling, parental employment and finances. Families made suggestions on how to modify the future trial design to mitigate such effects.

CONCLUSION

This study provides guidance from patients and parents on T2T targets and study designs. Complementary quantitative studies assessing the achievability and impact of different targets (e.g. lupus low disease activity state or remission) are now warranted to inform an international consensus process to develop treatment targets.

Engaging the Voices of Children: A Scoping Review of How Children and Adolescents Are Involved in the Development of Quality-of-Life-Related Measures

OBJECTIVES

Patient-reported outcomes are increasingly recommended to guide patient care, develop and evaluate interventions, and modify health systems. However, not enough is known about whether and how children and adolescents, as "experts" in their own health and quality of life (QoL), are being engaged in the development of instruments. Our goals in this review were (1) to identify all QoL-related instruments that have included children and/or adolescents in the development of questionnaire content, including identification of themes and items; and (2) to report how this was done; and (3) to highlight those that used qualitative methods.

METHODS

MEDLINE and Embase were searched for child- or adolescent-completed QoL-related instruments, supplemented by hand-searching of relevant reviews until 2020. Original development papers were identified and retrieved when possible, from which instrument characteristics and details of qualitative development methods were extracted.

RESULTS

We identified 445 instruments, of which 88 used qualitative methods for content development. Interviews and focus groups were the most common methods. A variety of play techniques were used to engage the child and adolescent participants. The specific criteria for the inclusion of children and adolescents (age, developmental stage, duration, and nonclinical location) varied considerably.

CONCLUSIONS

Researchers frequently involve children and adolescents in qualitative methods when developing QoL-related measures; however, there is little information about the methods used. Better reporting of methodology, improved dissemination of methods guidelines, and research into optimal ways of including children and adolescents in the process of instrument development would be useful.

Multi-pronged approach to enhance education of children and adolescents with lupus, caregivers, and healthcare providers in New Jersey: Needs assessment, evaluation, and development of educational materials

BACKGROUND

Childhood Systemic Lupus Erythematosus (cSLE) patients are younger at diagnosis and have a more severe disease course compared to adult onset SLE patients and develop significant complications related to disease and or immunosuppression. Moreover, female and minority populations experience higher rates of cSLE, with African American, Afro-Caribbean, and Hispanic populations being at greatest risk and having poor prognosis.

METHODS

The Pediatric Alliance for Lupus initiative addressed the dearth in education and resources in a multi-stage process. First, we conducted a need assessment identifying knowledge gaps among healthcare providers (HCPs), and resources needed to care for cSLE patients and their families. Second, we educated HCPs about the diagnosis and treatment of cSLE by Continuing Medical Education (CME) sessions/webinars (presented here). Third, HCPs participated in a Quality Improvement (QI) program on cSLE approved by the American Board of Pediatrics Maintenance of Certification Part 4. Finally, patients and caregivers were educated through the development of appropriate, culturally and linguistically sensitive cSLE resources. PAL disseminated materials among HCPs and the community to improve the awareness of the availability of these materials.

RESULTS

According to results from the statewide needs assessment (representative of every county throughout NJ), HCPs face significant challenges in providing care to cSLE patients and their families, in part due to the multi-systemic nature of the autoimmune disease.

CONCLUSION

Based on this need, we developed educational sessions, with pre-post comparison data showing a significant increase in knowledge after HCP education. The 15 different materials developed as part of the endeavor is a major contribution to the cSLE community, HCPs and pediatric rheumatologists. Resources are available in multiple formats (PDF and web pages), and are accessible on the National Resource Center on Lupus, the latest web site of the Lupus Foundation of American that houses materials for SLE patients, their families, schools, HCPs, and the community at large.Improving cSLE knowledge will empower the children and adolescents and families by increasing their self-efficacy; and positively impact key health outcomes (transition readiness and HRQOL) that are not optimally addressed with current medical treatment alone.

Effect of Mental Health Problems on the Quality of Life in Children with Lupus Nephritis

INTRODUCTION

Mental health problems, such as anxiety, depression, and ineffective family coping, in children with lupus nephritis (LN) can increase the severity and affect the management of the disease, thus affecting the quality of life (QoL) of patients.

OBJECTIVE

Analyzing the association between levels of depression, anxiety, coping, disease activity on the QoL of pediatric patients with LN.

PATIENTS AND METHODS

There were 62 pediatric LN participants (16 participants in the induction phase and 46 participants in the maintenance phase). Participants were measured for anxiety, depression, coping, disease activity (systemic lupus erythematosus disease activity index/SLEDAI), and QoL. The measurement results were compared between induction and maintenance groups. Analysis of the association between anxiety, depression, coping, and disease activity with the QoL of children with LN used a multiple logistic regression test with p <0.05.

RESULTS

The measurement results obtained anxiety (induction = 69.06±3.92 and maintenance = 45.24±10.33; p <0.001), depression (induction = 69.88±3.34 and maintenance = 42.20±9.12; p <0.001), coping (induction = 99.88±12.93 and maintenance = 115.67±7.34; p <0.001), SLEDAI (induction = 15.81±12.58 and maintenance = 0.43±1.26; p <0.001), and QoL (induction = 49.92±12.44 and maintenance = 88.15±8.06; p <0.001).. Anxiety level in the induction group (p = 0.043) and maintenance group (p <0.001; p = 0.032; p = 0.008; p = 0.009). Depression level in the induction group (p = 0.031) and maintenance group (p = 0.024; p = 0.042; p = 0.003). SLEDAI score in the maintenance group (p = 0.003; p = 0.003). Coping in induction group (p = 0.016; p = 0.016) and maintenance group (p = 0.005).

CONCLUSION

Mental health disorders reduce the QoL of LN children, and the level of QoL in induction phase is lower than maintenance phase.

Examining Uncertainty in Illness in Parents and Children With Chronic Kidney Disease and Systemic Lupus Erythematosus: A Mediational Model of Internalizing Symptoms and Health-Related Quality of Life

To examine if parent illness uncertainty is indirectly associated with child depression, anxiety, and HRQOL in the CKD/SLE population. Parent-child dyads (N = 31) from outpatient rheumatology and nephrology clinics included children (ages 9-18) diagnosed with CKD (Stage 1, 2, or nephrotic syndrome) or SLE. Parents completed demographic and uncertainty measures and children completed uncertainty, depression, anxiety, and HRQOL measures. This cross-sectional study examined mediational models using the percentile bootstrapping method. Parent uncertainty had an indirect effect on child depression, anxiety, and HRQOL through the mediator, child uncertainty. In other words, parents' illness uncertainty regarding their child's condition correlates to the child's illness uncertainty, which then is associated with the child's mental health and wellbeing. Reverse mediations illustrated that parent uncertainty did not mediate child uncertainty and outcome variables. Results extend previous research by examining parent and child illness uncertainty in understudied conditions (CKD/SLE) and the relationship to outcome variables commonly related to depression (e.g., anxiety and HRQOL). Findings allow health psychologists and medical personnel to understand the impact of uncertainty on the child's wellbeing and HRQOL. Clinical implications, including using specialized interventions to address illness uncertainty, are discussed.

A North American perspective of content and quality of websites in the English language on childhood-onset lupus erythematosus

Objective The objective of this article is to examine the quality, content, and readability of information and resources in the English language and accessible on the internet by pediatric patients with systemic lupus erythematosus (SLE) and their families in North America. Methods Keywords relevant to SLE were generated by an undergraduate student, a first-year medical student, and a third-year pediatric resident, and a search was conducted across five commonly used search engines. Quality of information found was evaluated independently by an undergraduate student, a graduate student, a first-year medical student, and a third-year pediatric resident using the DISCERN tool. Two pediatric rheumatologists assessed website accuracy and completeness. Readability of websites was determined using the Flesch-Kincaid grade level and Reading Ease score. Results Out of 2000 websites generated in the search, only 34 unique websites met inclusion criteria. Only 16 of these websites had DISCERN scores above 50% (fair quality). Overall quality of website information was fair with mean ±standard deviation (SD) DISCERN quality score of 44 ± 7 (range: 30-56). Only nine websites of 34 had DISCERN scores above 50 (>66%, indicating greater quality) and were further assessed for completeness. Flesch-Kincaid grade level was 11 ± 1 (mean±SD) and reading ease score was 39 ± 10 (mean±SD, range of 11-61). Conclusion Our study highlights the need for more complete, readable information regarding the unique needs of pediatric patients with childhood-onset SLE and their families.

Lupus Means Sacrifices: Perspectives of Adolescents and Young Adults With Systemic Lupus Erythematosus

OBJECTIVE

Disease activity, organ damage, and treatment burden are often substantial in children and adolescents with systemic lupus erythematous (SLE), and the complex interplay among the developing child, parents, and peers makes effective management difficult. We aimed to describe the experiences and perspectives of adolescents and young adults diagnosed with juvenile-onset SLE to inform strategies for improving treatment and health outcomes.

METHODS

Focus groups and face-to-face semistructured interviews were conducted with 26 patients ages 14-26 years, from 5 Australian hospitals in 2013-2014. Focus groups and interview transcripts were thematically analyzed.

RESULTS

Five themes were identified: marring identity (misrepresented self, heightened self-consciousness, sense of isolation), restricting major life decisions (narrowed career options, threat to parenthood), multifaceted confusion and uncertainty (frustration at delayed diagnosis or misdiagnosis, needing age and culturally appropriate information, ambiguity about cause of symptoms, prognostic uncertainty, confronting transition to adult care), resentment of long-term treatment (restricting ambition, animosity toward medication use), and gaining resilience and coping capacities (desire for independence, developing self-reliance, recalibrating perceived disease severity, depending on family and friends, trusting physicians).

CONCLUSION

Young patients with SLE perceive they have substantially limited physical and social capacities and restricted personal and career goals. Psychosocial and educational interventions targeted at improving confidence, self-efficacy, disease-related knowledge, and social support, and at resolving insecurities regarding patients' capacity for self-management may alleviate psychosocial distress and improve adherence, and thus optimize health outcomes of adolescents and young adults with SLE.

Relationship between health-related quality of life, disease activity and disease damage in a prospective international multicenter cohort of childhood onset systemic lupus erythematosus patients

Previously, we described associations between health-related quality of life (HRQOL) and disease-related factors among childhood onset systemic lupus erythematosus (cSLE) patients. Here we determined the relationship between HRQOL, disease activity and damage in a large prospective international cohort of cSLE. We compared HRQOL, disease activity and disease damage across different continents and examined the relationship between children's and parents' assessments of HRQOL. Patients with cSLE and their parents completed HRQOL measures at enrollment and ≥4 follow-up visits. Physicians assessed disease activity and damage. The multinational cohort ( n = 467) had relatively low disease activity and damage. Patient and parent HRQOL scores were significantly correlated. Asian and European patients had the highest HRQOL, while South and North American patients had lower HRQOL scores. Renal, CNS, skin and musculoskeletal systems exhibited the highest levels of damage. North and South American and Asian patients were more likely to have disease damage and activity scores above median values, compared with Europeans. Asians were more likely to use cyclophosphamide/rituximab. Female gender, high disease activity and damage, non-White ethnicity, and use of cyclophosphamide and/rituximab were related to lower HRQOL. HRQOL domain scores continue to emphasize that SLE has widespread impact on all aspects of children's and parents' lives.

The illness experience of youth with lupus/mixed connective tissue disease: a mixed methods analysis of patient and parent perspectives

OBJECTIVE

We aimed to develop a model of the illness experience for youth with systemic lupus erythematosus (SLE)/mixed connective tissue disease (MCTD).

METHODS

We conducted 32 semi-structured interviews with 16 outpatient youth with SLE/MCTD, age 11 to 22 years, and their parents. We qualitatively defined key features of illness for families and distinguished profiles of youth adapting well vs poorly to SLE/MCTD. We then related these profiles to features of illness, patient-level attributes and outcomes.

RESULTS

Experiences with SLE/MCTD grouped into five themes: managing disease, limitations, stigma, illness uncertainty and psychological coping. Youth adapting well experienced minimal challenges in these areas. Youth adapting poorly (4/16) experienced significant challenges in >1 thematic area, and were older with lower socioeconomic status, quality of life and psychosocial functioning, and increased disease-related morbidity. They also described suboptimal treatment adherence, healthcare utilization and transition to adult care. These findings support a dynamic model in which illness adaptation and outcomes are shaped by patient characteristics and five central illness-related challenges.

CONCLUSION

Further testing of our model of illness experience may help guide comprehensive and personalized care of youth with SLE/MCTD, with targeted supports for youth at risk for negative adaptation to illness and poor outcomes.

Quality of life in Japanese female patients with systemic lupus erythematosus: Evaluation using the Short Form 36 Health Survey

OBJECTIVE

Aspects of health-related quality of life (HRQoL) are important for assessing perceived health status and treatment burden. We evaluated HRQoL using Short Form 36 Health Survey (SF-36) and factors associated with HRQoL.

METHODS

We collected basic and lifestyle-related, clinical, and treatment characteristics among 119 female Japanese patients with systemic lupus erythematosus (SLE). Odds ratios (ORs) and their 95% confidence intervals were assessed for associations between HRQoL and selected factors.

RESULTS

Irregularity of sleep was significantly associated with risk of lower role physical (RP) (OR = 8.27), vitality (VT) (OR = 8.45), and role emotional (OR = 10.7) domains. Compared with clerical work, non-clerical work was significantly associated with risk of lower RP (OR = 7.39), and unemployment was significantly associated with risk of lower VT (OR = 41.0). Daily soybean intake was associated with improved General Health or GH (OR = 0.17). Compared with Systemic Lupus Collaborative Clinics Damage Index (SDI) = 0, SDI > 2 was associated with risk of lower PF (OR = 7.88), RP (OR = 4.29), and bodily pain (OR = 3.06) domains.

CONCLUSION

Reduced HRQoL was observed in our SLE patients. Interventions addressing sleep and work disturbances, as well as daily soybean consumption, could alter the HRQoL of SLE patients.

An update on cross-cultural adaptation of US English SMILEY

We previously developed a health-related quality of life (HRQOL) tool for children with systemic lupus erythematosus (SLE) that is valid in English for the United States, called Simple Measure of Impact of Lupus Erythematosus in Youngsters (SMILEY). In order to determine the effect of SLE on the well-being of children, adolescents and their parents and examine the response to treatment modalities, it is critical to have an HRQOL tool that is applicable for different cultures. After validation in US English, we reported the translation and cultural adaptation process undertaken by our team to make SMILEY available in the following 13 accepted modern language variants: Danish, Dutch, French (France), German (Germany), Hebrew, Italian, Portuguese (Brazil), Slovene, Spanish (USA and Puerto Rico), Spanish (Spain), Spanish (Argentina), Spanish (Mexico) and Turkish. In this report we will describe the translation and adaptation of SMILEY into Afrikaans, Xhosa, Arabic (Saudi Arabia), Arabic (Egypt), Chinese, Czech, English (UK), German (Austria), German (Switzerland), Greek, Hindi, Hungarian, Japanese, Romanian, Serbian and Spanish for Venezuela. We followed the earlier reported procedure in this study consisting of: establishing collaborative relationships with different physicians caring for children with rheumatic diseases; forward and back translation of SMILEY and revisions; and cultural adaptation of SMILEY content.

Validation of the Portuguese Simple Measure of Impact of Lupus Erythematosus in Youngsters (SMILEY) in Brazil

BACKGROUND AND OBJECTIVE

Simple Measure of the Impact of Lupus Erythematosus in Youngsters (SMILEY) is a health-related quality of life (HRQOL) assessment tool for pediatric systemic lupus erythematosus (SLE), which has been translated into Portuguese for Brazil. We are reporting preliminary data on cross-cultural validation and reliability of SMILEY in Portuguese (Brazil).

METHODS

In this multi-center cross-sectional study, Brazilian children and adolescents 5-18 years of age with SLE and parents participated. Children and parents completed child and parent reports of Portuguese SMILEY and Portuguese Pediatric Quality of Life Inventory (PedsQL™) Generic and Rheumatology modules. Parents also completed the Childhood Health Assessment Questionnaire (CHAQ). Physicians completed the SLE disease activity index (SLEDAI), Physician's Global Assessment of disease activity (PGA) and Systemic Lupus Erythematosus International Collaborating Clinics ACR Damage Index (SDI).

RESULTS

99 subjects (84 girls) were enrolled; 93 children and 97 parents filled out the SMILEY scale. Subjects found SMILEY relevant and easy to understand and completed SMILEY in 5-15 minutes. Brazilian SMILEY was found to have good psychometric properties (validity and reliability), and the child-parent agreement was moderate.

CONCLUSION

SMILEY may eventually be used routinely as a research/clinical tool in Brazil. It may be also adapted for other Portuguese-speaking nations offering critical information regarding the effect of SLE on HRQOL for children with SLE.

Psychosocial functioning of children with systemic lupus erythematosus

AIMS

Systemic lupus erythematosus (SLE) is a chronic illness in children. Involvement of multiple systems; the chronicity, as well as the treatment, has had great impact on children and their families. The objective of this study was to assess emotional and behavioural problems in childhood lupus during disease remission.

METHODS

Children with SLE and healthy controls, aged 8-15 years, were studied. Disease remission was confirmed by using the SLE Disease Activity Index (SLEDAI). The Children's Depression Inventory (CDI) and Multidimensional Anxiety Scale for Children (MASC) were rated by the children themselves. The Child Behaviour Checklist was completed by their parents.

RESULTS

The sample included 40 children with SLE and 40 controls. Their mean age was 12.9 ± 2.1 and 12.1 ± 1.8 years in the SLE and control groups, respectively. The average duration of the disease was 2.6 years. The SLEDAI in the SLE group ranged from 0-1, indicating inactive disease. The mean CDI scores were 8.9 and 10.9 in lupus children and controls, respectively. The mean MASC score was 44.7 in children with SLE and 48.4 in controls. The internalizing, externalizing and total behavioural scores were not significantly different in both groups (9.0 vs. 10.6; 6.6 vs. 8.1; 27.3 vs. 32.5). Only the social competence score was lower in children with SLE (P= 0.03).

CONCLUSIONS

SLE is a multi-system involvement disease with wide ranging effects on children's physical and psychosocial functioning. However, children with SLE, during inactive disease, were not found to be at increased risk of psychosocial dysfunctions.

Worldwide incidence and prevalence of pediatric onset systemic lupus erythematosus

Compilation of worldwide data regarding the incidence and prevalence of pediatric-onset systemic lupus erythematosus (SLE) is needed in order to evaluate the scope of the disease in the pediatric population. A literature review was performed to unify the current data available on the global incidence and prevalence of pediatric-onset SLE. We examined 13 available epidemiological studies concentrated on the incidence and prevalence of pediatric-onset SLE. The available reports were predominantly from North America, Europe and Asia. The limited amount of studies available highlights the need for more epidemiological research in order to better comprehend the global scope of this disease.

The role and effect of complementary and alternative medicine in systemic lupus erythematosus

The use of complementary and alternative medicine (CAM) is common among patients with systemic lupus erythematosus (SLE), especially those with active disease who often have poorer quality of life and significant unmet needs. It is important for the rheumatologist to be aware of these therapies and to ask the patient with SLE about their active use or future interest in CAM. Future studies on the effectiveness of the aforementioned therapies will be crucial to find better ways for the rheumatologist to integrate their use into the care of the patient with SLE.

Epidemiologic, socioeconomic and psychosocial aspects in lupus erythematosus

Epidemiologic, socioeconomic, and psychosocial factors play an important role in health care and handling of patients with the various clinical forms of lupus erythematosus (LE). Patients with LE are mostly young women; adolescents and some ethnic groups are especially prone to a severe course of disease. The unpredictable and fluctuating flares of disease, the need for longterm treatment, and the side effects and damage caused by the disease itself severely reduce quality of life. Problems arise, involving family members, adherence to medical advice and therapy, communication and self management. Socioeconomically, patients are often unable to take regular employment and to pay for health insurance. Stress factors that arise have a negative impact on the course of disease, increasing both fatigue and the basic burden of illness. Healthcare professionals must pay careful attention to all these items, as they attempt to treat flares, minimize drug side effects, provide pain relief, arrange communication and exercise programs along with behavioral and psychosocial interventions in multidisciplinary cooperation, and also involve and support family members.

Impact of lupus on school attendance and performance

Cognitive impairment in children and adolescents with systemic lupus erythematosus (SLE) can affect intelligence, academic achievement, arithmetic, reading comprehension, learning, visual memory and complex problem solving ability. In this prospective two-center study, we examined children’s (and adolescents’) and parents’ perception of the impact of SLE on school; the relationship between child and parent reports on school-related issues; and the relationship between health-related quality of life (HRQOL) and school-related issues. Patients aged 9—18 years with SLE and their parents completed corresponding child and parent reports of the SLE-specific HRQOL scale, Simple Measure of Impact of Lupus Erythematosus in Youngsters (SMILEY©), and PedsQLTM generic and rheumatology modules. Patients also completed questions related to school attendance and performance. Qualified physicians assessed SLE activity, damage and severity. Forty-one patients (73% girls) with SLE with mean age of 15 ± 3 years and 32 parents participated. Mean school domain scores for child and parent reports of the PedsQL TM generic report were lower compared with total and subscale scores. Patients reported difficulty with schoolwork, had problems with memory and concentration, and were sad about the effect of SLE on schoolwork and attendance. Moderate to strong correlations were found between child and parent reports on school-related items from all questionnaires. Eighty-three percent of patients felt that they would have done better in school if they did not have SLE. Moderate correlations (r = 0.3—0.4) were found between SMILEY © total score and the following items: satisfaction with school performance, interest in schoolwork, remembering what was learned, and concentrating in class. Patients on intravenous chemotherapeutic medications missed more school days (p < 0.05) compared with patients on oral medications. Also, patients with a greater number of missed school days had increased disease activity (p = 0.008). SLE and activities related to caring for the disease clearly impose a burden on children’s school attendance and performance. School-related activities can have a significant impact on HRQOL in children and adolescents with SLE. Detailed examination of the impact of SLE on attendance and the various aspects of school performance will enable us to formulate interventions in school for these children and adolescents. Lupus (2010) 19, 620—627.

Preliminary cross-cultural adaptation of a new pediatric health-related quality of life scale in children with systemic lupus erythematosus: an international effort

We developed a brief, new health-related quality of life measure for children with systemic lupus erythematosus that is valid in English for the United States, called Simple Measure of Impact of Lupus Erythematosus in Youngsters© (SMILEY©). The United States-English language questionnaire may not be applicable to most of the countries in the world and several United States population subgroups, such as Hispanics. In order to measure the impact of morbidity of systemic lupus erythematosus on the lives of children, adolescents, and their parents and assess the outcome of new therapies, it is critical to have a uniform measure of systemic lupus erythematosus-specific health-related quality of life that is valid for different cultures. We report the translation and cultural adaptation process undertaken by our team with the goal of cross-cultural validation of SMILEY© in the following thirteen languages: Danish, Dutch, French (France), German (Germany), Hebrew, Italian, Portuguese (Brazil), Slovene, Spanish (USA and Puerto Rico), Spanish (Spain), Spanish (Argentina), Spanish (Mexico), and Turkish. We employed the following steps: establishing collaborative relationships with institutions across the globe; forward and back translation of SMILEY© text; and cultural adaptation of SMILEY© content. We are in the process of enrolling patients and conducting validation of the translated and adapted versions of SMILEY©. Lupus (2010) 19, 83—88.

Relationship between health-related quality of life and SLE activity and damage in children over time

We previously described the development and validation of the 'Simple Measure of the Impact of Lupus Erythematosus in Youngsters' (SMILEY) for the reliable assessment of health-related quality of life (HRQOL) in children with systemic lupus erythematosus (SLE). The objectives of this new study were to determine the relationship of SMILEY scores to patient's/parent's assessment of HRQOL and SLE status, and physician's assessment of disease activity and damage over time. In this multicentre study, 68 children with SLE and parents completed SMILEY including the global HRQOL and SLE status assessments, physicians completed disease activity and damage tools at two time-points. Spearman rho was calculated between SMILEY scores and other scales, and between interval changes in SMILEY scores and other scales. SMILEY scores correlated with patient/parent assessments of global HRQOL and SLE status, disease activity and damage, confirming previous findings. The change in disease activity and damage measures correlated most strongly with the changes in SMILEY domains, Limitation and Burden of SLE. Results provide preliminary evidence that Limitation and Burden of SLE domains of SMILEY reflect the impact of disease activity and damage on HRQOL.

The challenges of transferring chronic illness patients to adult care: reflections from pediatric and adult rheumatology at a US academic center

BACKGROUND

Little is known about the transfer of care process from pediatric to adult rheumatology for patients with chronic rheumatic disease. The purpose of this study is to examine changes in disease status, treatment and health care utilization among adolescents transferring to adult care at the University of California San Francisco (UCSF).

METHODS

We identified 31 eligible subjects who transferred from pediatric to adult rheumatology care at UCSF between 1995-2005. Subject demographics, disease characteristics, disease activity and health care utilization were compared between the year prior to and the year following transfer of care.

RESULTS

The mean age at the last pediatric rheumatology visit was 19.5 years (17.4-22.0). Subject diagnoses included systemic lupus erythematosus (52%), mixed connective tissue disease (16%), juvenile idiopathic arthritis (16%), antiphospholipid antibody syndrome (13%) and vasculitis (3%). Nearly 30% of subjects were hospitalized for disease treatment or management of flares in the year prior to transfer, and 58% had active disease at the time of transfer. In the post-transfer period, almost 30% of subjects had an increase in disease activity. One patient died in the post-transfer period. The median transfer time between the last pediatric and first adult rheumatology visit was 7.1 months (range 0.7-33.6 months). Missed appointments were common in the both the pre and post transfer period.

CONCLUSION

A significant percentage of patients who transfer from pediatric to adult rheumatology care at our center are likely to have active disease at the time of transfer, and disease flares are common during the transfer period. These findings highlight the importance of a seamless transfer of care between rheumatology providers.

Health-related Quality of Life and Its Relationship to Patient Disease Course in Childhood-onset Systemic Lupus Erythematosus

Objective.

To (1) estimate the health-related quality of life (HRQOL) of children with childhood-onset systemic lupus erythematosus (cSLE) and compare it to that of normative cohorts; (2) assess the relationship of HRQOL with cSLE disease activity and damage; and (3) determine the effects of changes of disease activity on HRQOL.

Methods.

Patients with cSLE (n = 98) followed every 3 months completed HRQOL measures, the Pediatric Quality of Life Inventory Generic Core scale (PedsQL-GC), the Rheumatology Module (PedsQL-RM), and the Child Health Questionnaire (CHQ). The British Isles Lupus Activity Group Index (BILAG) was used to measure organ-system-specific disease activity. Physicians rated the course of cSLE between visits.

Results.

At baseline, mean (standard deviation, SD) score [parent report] of the PedsQL-GC and the PedsQL-RM was 75 (17) and 79 (14), respectively; the mean (SD) of the CHQ physical summary score (CHQ-PHS) was 49 (7) and that of the CHQ psychological summary score was 42 (12). Higher BILAG scores, especially in the general, musculoskeletal, neurological, and vascular, but not the mucocutaneous, renal, cardiovascular, or hematological BILAG domains, were associated with a significantly lower HRQOL. Patients with damage had lower HRQOL than those without damage. All HRQOL measures included were at most modestly responsive to clinically important changes with cSLE.

Conclusion.

HRQOL with cSLE is significantly lower than that reported in healthy populations. Organ-specific involvement with cSLE has a differential effect on HRQOL. Higher disease activity and damage are associated with significantly lower HRQOL as measured by the PedsQL-RM and the CHQ-PHS, and worsening of cSLE leads to a further decline.

Quality of life in children with systemic lupus erythematosus: a review

Systemic lupus erythematosus (SLE) in children is a chronic multisystem disease with wide ranging effects on their quality of life (QOL). While SLE's impact on different arenas of life and well-being has been extensively examined in the adult population, its effect on children has not received adequate attention. This review discusses the multidimensional aspect of QOL, the biopsychosocial implications of SLE, factors complicating QOL measurement in the affected population, and the different generic and disease-specific scales used for measuring QOL and related constructs. Until now, there have not been any pediatric SLE-specific health-related QOL (HRQOL) scales. A section is devoted to a novel instrument developed specifically for measuring QOL in pediatric lupus called the Simple Measure of the Impact of Lupus Erythematosus in Youngsters (SMILEY). SMILEY is a brief, easily understood, valid, reliable and internally consistent pediatric SLE-specific QOL scale and will be a useful adjunct to clinical trials and outcomes research.

Multicenter validation of a new quality of life measure in pediatric lupus

OBJECTIVE

Pediatric systemic lupus erythematosus (SLE) is a chronic fluctuating disease that significantly impacts quality of life (QOL). There is no pediatric SLE-specific health-related QOL (HRQOL) scale. Our objective was to develop and validate a new pediatric SLE-specific HRQOL scale.

METHODS

We developed the Simple Measure of the Impact of Lupus Erythematosus in Youngsters (SMILEY) based on results of qualitative research of children with SLE and their parents. SMILEY has parallel child and parent reports with a 5-faces scale for responses. SMILEY comprises 4 domains: effect on self, limitations, social, and burden of SLE. In this cross-sectional study, we examined face, content, construct, and concurrent validity; internal consistency; test-retest reliability; and child-parent agreement for SMILEY. Children </=18 years of age with SLE and their parents completed corresponding child and parent SMILEY reports, as well as other QOL and physical function scales. Qualified physicians assessed SLE activity, damage, and severity.

RESULTS

Eighty-six children with SLE and 80 parents participated. SMILEY was found to have face, content, construct, and concurrent validity (Spearman's rank correlation [r(s)] >/=0.4); test-retest reliability (intraclass correlation coefficient [ICC] 0.9); and internal consistency (alpha = 0.9). Moderate agreement was found between child and parent SMILEY reports (ICC 0.7, r(s) = 0.5, P < 0.001).

CONCLUSION

SMILEY is a brief, easily understood, valid, and reliable pediatric SLE-specific QOL scale. Because SMILEY assesses children's self-perception of QOL as impacted by SLE, we predict that it will have great utility in clinical practice, clinical trials, and outcomes research.

Adolescent development and SLE

Adolescence is a time of profound biological and psychosocial change. The management of a complex chronic condition such as systemic lupus erythematosus (SLE) during this period is a challenging but rewarding task for the clinician. Early diagnosis and optimal disease control is essential in order to facilitate normal adolescent development and minimize long-term disease sequelae. Current treatment regimens are associated with significant toxicity in young people, and there is a need for new, less toxic regimens. There are currently no controlled therapeutic studies in adolescents with SLE. Those involved in the care of these young people must ensure that they have appropriate access to specialist medical services while ensuring that their specific needs as adolescents in the health-care system are addressed.

Quality of life in children with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) in children is a chronic multi-system disease with wide ranging effects on their quality of life (QOL). While SLE's impact on different arenas of life and well-being has been extensively examined in the adult population, its effect on children has not received adequate attention. This paper briefly discusses the multidimensional aspect of QOL, the biopsychosocial implications of SLE, factors complicating QOL measurement in the affected population, and the different generic and disease-specific scales used for measuring QOL and related constructs, and it also highlights the need for SLE-specific pediatric QOL instruments.

Outcome in juvenile onset systemic lupus erythematosus

PURPOSE OF REVIEW

Over the past 2 decades, there has been a marked improvement in survival among patients with juvenile-onset systemic lupus erythematosus. As a result of the increased life expectancy, children and adolescents with systemic lupus erythematosus are now faced with considerable morbidity resulting from sequelae of disease activity, side effects of medications, and comorbid conditions. This morbidity affects physical and psychosocial well-being. Therefore, the need is increasing for monitoring the development of irreversible organ damage and the effect of the disease and its treatment on daily life. This review summarizes the recent advances in the investigation on survival, accumulated damage, and health-related quality of life in patients with juvenile-onset systemic lupus erythematosus.

RECENT FINDINGS

The 5-year survival rate of patients with juvenile-onset systemic lupus erythematosus approaches 100%, and the 10-year survival rate is close to 90%. The development of cumulative organ damage has been observed in 50-60% of patients. Children and adolescents with systemic lupus erythematosus have been found to have poorer health-related quality of life, particularly in the physical domain, and lower socioeconomic achievements than their healthy peers.

SUMMARY

The prolongation of the life span of patients with juvenile-onset systemic lupus erythematosus has been accompanied by a substantial risk of damage accumulation and has not been paralleled by an improvement in health-related quality of life. This problem highlights the need of measuring cumulative organ damage and health-related quality of life in the long-term follow-up of patients with juvenile-onset systemic lupus erythematosus and of designing new treatments and treatment strategies that are aimed not only at improving control of disease activity but also at minimizing the development of nonreversible damage.