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Xing C, Trivedi J, Bitencourt N, Burns DK, Reisch JS, Cai C. Myxovirus resistance protein A (MxA) expression in myositides: Sarcoplasmic expression is common in both dermatomyositis and lupus myositis. Muscle Nerve 2024; 69:548-555. [PMID: 38372203 DOI: 10.1002/mus.28066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/26/2024] [Accepted: 02/03/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION/AIMS Myxovirus resistance protein A (MxA) is a type I interferon (IFN1) pathway activation marker and MxA sarcoplasmic expression is currently recognized as a highly specific marker for dermatomyositis (DM). However, we have frequently observed endothelial tubuloreticular inclusions (TRI), another surrogate IFN1 activation marker, in a variety of overlap myositides. The aim of this study was to examine MxA expression in those myositides. METHODS We retrospectively performed MxA immunostaining on a wide range of myositides. RESULTS MxA sarcoplasmic expression was present in DM (94.4%, 17/18), active lupus myositis (LM, 80%,16/20), inactive LM (36%, 4/11), antisynthetase syndrome (ASyS, 20%, 2/10), systemic sclerosis (13%, 2/15), Sjogren's syndrome (7.7%, 1/13), and human immunodeficiency virus (HIV) myositis (5.6%, 1/18) and was absent in immune-mediated necrotizing myopathy (IMNM, 0/16) and hydroxychloroquine myopathy (0/5). The sensitivity and specificity of MxA sarcoplasmic expression for LM and DM combined compared with all other myositides were 84.6% (95% CI: 69.5-94.1) and 92.1 (95% CI: 83.6-97.0), respectively, and superior to TRIs. MxA capillary expression was nonspecific. Histologically, 35% of LM cases demonstrated a unique panfascicular necrotizing myopathy pattern. The remainder of the LM cases had significant morphological overlap with DM/ASyS (20%), IMNM (20%), or polymyositis (15%). DISCUSSION MxA sarcoplasmic expression is highly prevalent in LM and DM and is a useful marker in differentiating DM and LM from other myositides. LM can manifest in various pathology patterns that need to be differentiated from DM, IMNM, ASyS, and polymyositis.
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Affiliation(s)
- Changhong Xing
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jaya Trivedi
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole Bitencourt
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dennis K Burns
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Joan S Reisch
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Chunyu Cai
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Chang JC, Sears C, Bitencourt N, Peterson R, Alperin R, Goh YI, Overbury RS, Sadun R, Smitherman E, White PH, Lawson EF, Carandang K. Implementation of Rheumatology Health Care Transition Processes and Adaptations to Systems Under Stress: A Mixed-Methods Study. Arthritis Care Res (Hoboken) 2023; 75:689-696. [PMID: 34806346 DOI: 10.1002/acr.24822] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/26/2021] [Accepted: 11/16/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Despite poor health care transition outcomes among young adults with pediatric rheumatic diseases, adoption of transition best practices is low. We sought to understand how structured transition processes were operationalized within pediatric rheumatology practices and what factors were perceived to enable adaptations during a global pandemic. METHODS We conducted a mixed methods study of team leaders' experiences during an interim analysis of a pilot project to implement transition policy discussions at sites in the Childhood Arthritis and Rheumatology Research Alliance Transition Learning Collaborative. We combined quantitative assessments of organizational readiness for change (9 sites) and semistructured interviews of team leaders (8 sites) using determinants in the Exploration, Preparation, Implementation, Sustainment Framework. RESULTS Engagement of nursing and institutional improvement efforts facilitated decisions to implement transition policies. Workflows incorporating educational processes by nonphysicians were perceived to be critical for success. When the pandemic disrupted contact with nonphysicians, capacity for automation using electronic medical record (EMR)-based tools was an important facilitator, but few sites could access these tools. Sites without EMR-based tools did not progress despite reporting high organizational readiness to implement change at the clinic level. Lastly, educational processes were often superseded by acute issues, such that youth with greater medical/psychosocial complexity may not receive the intervention. CONCLUSION We generated several considerations to guide implementation of transition processes within pediatric rheumatology from the perspectives of team leaders. Careful assessment of institutional and nursing support is advisable before conducting complex transition interventions. Ideally, new strategies would ensure interventions reach youth with high complexity.
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Affiliation(s)
- Joyce C Chang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, and Boston Children's Hospital, Boston, Massachusetts
| | - Cora Sears
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Rosemary Peterson
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, and Dell Children's Medical Center, Austin, Texas
| | | | - Y Ingrid Goh
- The Hospital for Sick Children, Toronto, Ontario, Canada, and SickKids Research Institute, Toronto, Ontario, Canada
| | | | - Rebecca Sadun
- Duke University Medical Center, Durham, North Carolina
| | | | - Patience H White
- Got Transition, The National Alliance to Advance Adolescent Health, and School of Medicine and Health Sciences, George Washington University, Washington, DC
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Smitherman EA, Chahine RA, Bitencourt N, Rahman AKMF, Lawson EF, Chang JC. Patient-Reported Outcomes Among Transition-Age Young Adults With Juvenile Idiopathic Arthritis in the Childhood Arthritis and Rheumatology Research Alliance Registry. J Rheumatol 2023; 50:98-106. [PMID: 36109074 DOI: 10.3899/jrheum.220514] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate patient-reported care utilization and outcomes among young adults with juvenile idiopathic arthritis (JIA), including factors associated with complete transfer to adult rheumatology. METHODS We included young adults with JIA enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from 2015 to 2019 with age ≥ 18 years at their last clinical site visit. We used data from the CARRA Registry Long-term Follow-up program, which follows inactive CARRA Registry patients and collects patient-reported information through phone surveys. We compared the characteristics of respondents with complete and incomplete transfer to adult rheumatology care at their first Long-term Follow-up phone survey. RESULTS We identified 540 young adults with JIA; 187 (35%) responded to the Long-term Follow-up phone survey. The 54% of respondents with complete transfer to adult rheumatology were slightly older and reported more self-assessed disease activity, morning stiffness, and pain compared to those with incomplete transfer. Biologic use was high at both timepoints and did not differ by transfer status. Patients who completed the transfer were more likely to have private insurance and be actively pursuing postsecondary education compared to those with an incomplete transfer. Across the cohort, 65% reported problems with pain or discomfort and 45% with anxiety or depression. CONCLUSION Young adult respondents with JIA in the CARRA Registry commonly report persistent medication use, but still report more problems with pain as compared to population norms. Additional work is needed to understand how best to address comorbid pain around the period of transition to adult care.
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Affiliation(s)
- Emily A Smitherman
- E.A. Smitherman, MD, MS, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama;
| | - Rouba A Chahine
- R.A. Chahine, PhD, Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, North Carolina
| | - Nicole Bitencourt
- N. Bitencourt, MD, Department of Pediatrics, Loma Linda University Health, Loma Linda, California
| | - A K M Fazlur Rahman
- A.K.M.F. Rahman, PhD, Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Erica F Lawson
- E.F. Lawson, MD, Department of Pediatrics, University of California San Francisco, San Francisco, California
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Bitencourt N, Lawson E, Bridges J, Carandang K, Chintagunta E, Chiraseveenuprapund P, DeQuattro K, Goh YI, Lee TC, Moore KF, Peterson RG, Roberts JE, Ronis T, Sadun RE, Smitherman EA, Stringer E, White PH, Chang JC. Pediatric to Adult Transition Literature: Scoping Review and Rheumatology Research Prioritization Survey Results. J Rheumatol 2022; 49:1201-1213. [PMID: 35914787 DOI: 10.3899/jrheum.220262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
The transition from pediatric to adult care is the focus of growing research. It is important to identify how to direct future research efforts for maximum effect. Our goals were to perform a scoping review of the transition literature, highlight gaps in transition research, and offer stakeholder guidance on the importance and feasibility of research questions designed to fill identified gaps. The transition literature on rheumatic diseases and other common pediatric-onset chronic diseases was grouped and summarized. Based on the findings, a survey was developed and disseminated to pediatric rheumatologists and young adults with rheumatic diseases as well as their caregivers. The transitional care needs of patients, healthcare teams, and caregivers is well described in the literature. While various transition readiness scales exist, no longitudinal posttransfer study confirms their predictive validity. Multiple outcome measures are used alone or in combination to define a successful transition or intervention. Multimodal interventions are most effective at improving transition-related outcomes. How broader health policy affects transition is poorly studied. Research questions that ranked highest for importance and feasibility included those related to identifying and tracking persons with psychosocial vulnerabilities or other risk factors for poor outcomes. Interventions surrounding improving self-efficacy and health literacy were also ranked highly. In contrast to healthcare teams (n = 107), young adults/caregivers (n = 23) prioritized research surrounding improved work, school, or social function. The relevant transition literature is summarized and future research questions prioritized, including the creation of processes to identify and support young adults vulnerable to poor outcomes.
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Affiliation(s)
- Nicole Bitencourt
- N. Bitencourt, MD, Department of Pediatrics, Loma Linda University Medical Center, Loma Linda, California, USA;
| | - Erica Lawson
- E. Lawson, MD, Department of Pediatrics, University of California San Francisco Medical Center, San Francisco, California, USA
| | - John Bridges
- J. Bridges, MD, MS, Division of Pediatric Rheumatology/Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kristine Carandang
- K. Carandang, PhD, OTR/L, Patients' Autoimmune Research & Empowerment Alliance, University of Wisconsin-River Falls, River Falls, Wisconsin, USA
| | - Ela Chintagunta
- E. Chintagunta, Patient Partner, Childhood Arthritis Rheumatology Research Alliance, Washington, DC, USA
| | - Peter Chiraseveenuprapund
- P. Chiraseveenuprapund, MD, Department of Pediatrics, Division of Allergy, Immunology, Rheumatology, and Kawasaki Disease, University of California, San Diego, San Diego, California, USA
| | - Kimberly DeQuattro
- K. DeQuattro, MD, MM, Department of Medicine, Division of Rheumatology, University of Pennsylvania Health Systems, Philadelphia, Pennsylvania, USA
| | - Y Ingrid Goh
- Y.I. Goh, PhD, Division of Rheumatology, The Hospital for Sick Children; Child Health Evaluative Services, SickKids Research Institute, Toronto, Ontario, Canada
| | - Tzielan C Lee
- T.C. Lee, MD, Pediatric Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - Katharine F Moore
- K.F. Moore, MD, Section of Pediatric Rheumatology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rosemary G Peterson
- R.G. Peterson, MD, MSCE, Department of Pediatrics, Division of Pediatric Rheumatology, Dell Medical School at UT Austin, Austin, Texas, USA
| | - Jordan E Roberts
- J.E. Roberts, MD, J.C. Chang, MD, MSCE, Division of Immunology, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Tova Ronis
- T. Ronis, MDCM, Pediatric Rheumatology, Children's National Hospital, Department of Pediatrics, George Washington University, Washington DC, USA
| | - Rebecca E Sadun
- R.E. Sadun, MD, PhD, Department of Pediatric and Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Emily A Smitherman
- E.A. Smitherman, MD, MS, Department of Pediatrics, Division of Pediatric Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth Stringer
- E. Stringer, MD, MSc, FRCPC, Associate Professor of Pediatrics, IWK Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patience H White
- P.H. White, MD, MA, Got Transition National Center, National Alliance to Advance Adolescent Health, Division of Rheumatology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Joyce C Chang
- J.E. Roberts, MD, J.C. Chang, MD, MSCE, Division of Immunology, Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
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Ciosek AL, Makris UE, Kramer J, Bermas BL, Solow EB, Wright T, Bitencourt N. Health Literacy and Patient Activation in the Pediatric to Adult Transition in Systemic Lupus Erythematosus: Patient and Health Care Team Perspectives. ACR Open Rheumatol 2022; 4:782-793. [PMID: 35716025 PMCID: PMC9469480 DOI: 10.1002/acr2.11474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 05/01/2022] [Accepted: 05/19/2022] [Indexed: 11/05/2022] Open
Abstract
Objective Methods Results Conclusion
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Affiliation(s)
| | - Una E. Makris
- University of Texas Southwestern Medical Center and Veterans Administration North Texas Health Care System Dallas
| | | | | | | | - Tracey Wright
- University of Texas Southwestern Medical Center, Texas Scottish Rite Hospital for Children, and Children's Health Dallas Dallas Texas
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Saez C, Nassi L, Wright T, Makris UE, Kramer J, Bermas BL, Solow EB, Bitencourt N. Therapeutic recreation camps for youth with childhood-onset systemic lupus erythematosus: perceived psychosocial benefits. Pediatr Rheumatol Online J 2022; 20:39. [PMID: 35672791 PMCID: PMC9171737 DOI: 10.1186/s12969-022-00702-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/02/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND The psychosocial burden of having a chronic disease can be substantial for adolescents with childhood-onset systemic lupus erythematosus (cSLE). Current literature is scarce on interventions that can improve psychosocial outcomes for this population. Therapeutic recreation camps have been proposed as a beneficial experience for chronically ill pediatric populations. However, their effective components have not been well characterized in patients with cSLE. In this study, we sought to understand the various components of the camp experience for adolescents with cSLE from both the patient and parent perspective. METHODS We recruited patients with cSLE who had participated in one or more annual, weekend-long recreational lupus camp(s) near Dallas, Texas. Semi-structured in-depth telephone interviews were conducted from March-June 2020 with both the patients and parents. Questions focused on overall patient experience, psychosocial impact of camp participation, coping skills gained, and opportunities to prepare for the transition from pediatric to adult care. Interviews were coded and analyzed using inductive thematic analysis. RESULTS We interviewed 9 current and former campers (ages 16-24), including a current camp counselor, and 3 of their parents separately. Reported benefits included a positive impact on social support through peer bonding, opportunities to develop coping mechanisms through structured activities and peer/medical staff interactions, opportunities for education about the cSLE disease experience, improved adherence through peer modeling, overall increase in self-efficacy, and better parental insight into the patient experience. Participants also provided suggestions for expansion and improvement in program development to optimize educational opportunities for both campers and parents. In addition, they advocated for longitudinal social support and community building. CONCLUSIONS In this qualitative study, in which cSLE patients and their parents reflected on their experiences with therapeutic recreation camps, we found several perceived benefits impacting the patient and parent experience. Participants expressed a desire for more educational opportunities that could contribute to their successful transition from pediatric to adult care. Further studies are needed to demonstrate the effects of therapeutic recreation camps on the psychosocial health of this population.
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Affiliation(s)
- Cristina Saez
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - Lorien Nassi
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA ,grid.416991.20000 0000 8680 5133Texas Scottish Rite Hospital for Children, Dallas, Texas USA
| | - Tracey Wright
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA ,grid.416991.20000 0000 8680 5133Texas Scottish Rite Hospital for Children, Dallas, Texas USA
| | - Una E. Makris
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA ,grid.422201.70000 0004 0420 5441Veterans Administration North Texas Health Care System, Dallas, Texas USA
| | - Justin Kramer
- grid.264756.40000 0004 4687 2082Texas A&M University, College Station, Texas USA
| | - Bonnie L. Bermas
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - E. Blair Solow
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, Texas USA
| | - Nicole Bitencourt
- Loma Linda University Medical Center, 11175 Campus Street, Coleman Pavilion, Loma Linda, CA, 92354, USA.
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Bitencourt N, Ciosek A, Kramer J, Solow EB, Bermas B, Wright T, Nassi L, Makris U. "You Just Have to Keep Going, You Can't Give Up": Coping mechanisms among young adults with lupus transferring to adult care. Lupus 2021; 30:2221-2229. [PMID: 34874764 DOI: 10.1177/09612033211061057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Coping mechanisms and emotional regulation are important contributors to psychosocial health during stressful life events. We sought to describe the coping and emotional responses of persons with childhood-onset systemic lupus erythematosus during the transfer from pediatric to adult healthcare. METHODS Semi-structured in-depth one-on-one interviews were conducted with 13 young women aged 18-24 of minority background who had transferred to adult care in a public hospital system. Thematic analysis was used to identify themes motifs from the data. RESULTS Participants described the use of (1) problem-focused coping such as the use of clear communication and self-education, (2) adaptive emotion-focused coping such as cognitive reframing and acceptance, (3) social coping including support-seeking, (4) meaning-making coping including positive religious framing and viewing events as learning opportunities for growth, and (5) disengaged coping including denial and social isolation. A range of emotional responses associated with the transfer were described including fear, anger, loss, and feelings of empowerment and excitement. CONCLUSION Effective coping and emotional regulation are modifiable factors that may impact transfer-related outcomes and psychosocial health. Addressing coping mechanisms is relevant to the optimized transfer to adult care.
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Affiliation(s)
- Nicole Bitencourt
- Division of Pediatric Rheumatology, 23335Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ashley Ciosek
- 25989University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Justin Kramer
- Department of Health and Kinesiology, 14736Texas A&M University, College Station, TX, USA
| | - E Blair Solow
- Division of Rheumatic Diseases, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bonnie Bermas
- Division of Rheumatic Diseases, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tracey Wright
- Division of Pediatric Rheumatology, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA.,Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Lorien Nassi
- Division of Pediatric Rheumatology, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA.,Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX, USA
| | - Una Makris
- Division of Rheumatic Diseases, 12334University of Texas Southwestern Medical Center, Dallas, TX, USA.,Medical Service, VA North Texas Health Care System, Dallas, TX, USA
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Bitencourt N, Makris UE, Solow EB, Wright T, Reisch EJ, Bermas BL. Predictors of Adverse outcomes in patients with systemic lupus erythematosus transitioning to adult care. Semin Arthritis Rheum 2021; 51:353-359. [PMID: 33601191 DOI: 10.1016/j.semarthrit.2021.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The transition from pediatric to adult care is a vulnerable period for individuals with chronic diseases. We sought to identify risk factors associated with poor outcomes in patients with childhood-onset systemic lupus erythematosus (cSLE) who have transitioned to adult care. METHODS A retrospective analysis of cSLE patients was performed. Outcomes of interest were development of end-stage renal disease (ESRD) or death and time to first hospitalization following final pediatric rheumatology visit. Multivariable logistic and Cox regression models were used. RESULTS Of 190 patients with cSLE, 21 (11%) developed ESRD and 9 (5%) died following the final pediatric rheumatology visit. In logistic regression, public insurance, history of Child Protective Services involvement, and an unscheduled hospitalization during the final year in pediatric care were predictive of ESRD or death (odds ratio (95% confidence intervals (CI)) 6.7 (1.5-30.7), 6.6 (2.3-19.1), and 3.2 (1.3-8.3), respectively). Among 114 patients with healthcare utilization data, 53% had a hospitalization in adult care. In Cox regression analysis, a pediatric outpatient opioid prescription was associated with shorter time to adult hospitalization and White or Asian race was associated with longer time to adult hospitalization (hazard ratio (CI) 3.5 (1.7-7.0) and 0.1 (0.03-0.4), respectively). CONCLUSIONS Risks factors associated with poor outcomes in adult care amongst patients with cSLE include public insurance, history of Child Protective Services involvement, unscheduled care utilization in pediatric care, pediatric outpatient opioid prescription, Black race and Hispanic ethnicity. Efforts to improve long-term outcomes among patients with cSLE should focus on these populations.
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Affiliation(s)
- Nicole Bitencourt
- Division of Pediatric Rheumatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas 75390-9063, TX, United States.
| | - Una E Makris
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States; Medical Service, VA North Texas Health Care System, Dallas, TX, United States; Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - E Blair Solow
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Tracey Wright
- Division of Pediatric Rheumatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas 75390-9063, TX, United States
| | - E Joan Reisch
- Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, TX, United States
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Bitencourt N, Kramer J, Bermas BL, Solow EB, Wright T, Makris UE. Clinical Team Perspectives on the Psychosocial Aspects of Transition to Adult Care for Patients With Childhood-Onset Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 73:39-47. [PMID: 32976698 DOI: 10.1002/acr.24463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/17/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The transition from pediatric to adult care for youth with childhood-onset systemic lupus erythematosus (SLE) is a vulnerable period. Adverse outcomes during this transition include gaps in care, unscheduled health care utilization, loss of insurance, and high disease activity. The objective of this study was to examine the clinical care teams' perspective on the psychosocial factors associated with transition outcomes, which are poorly understood in this population. METHODS We conducted in-depth interviews with clinical care team members who interact with childhood-onset SLE patients during transfer from pediatric to adult rheumatology. A semistructured interview guide was used to prompt participants' perspectives about the psychosocial factors associated with the transition process for patients with childhood-onset SLE. Audio recordings were transcribed and analyzed using the constant comparative method. We stopped conducting interviews once thematic saturation was achieved. RESULTS Thirteen in-depth interviews were conducted. Participants included pediatric rheumatologists (n = 4), adult rheumatologists from both academic and private practice settings (n = 4), nurses (n = 2), a nurse practitioner, a social worker, and a psychologist. We identified several themes deemed by clinical care teams as important during the transition, including the impact of the family, patient resilience and coping mechanisms, the role of mental health and emotional support, and the need for education, peer support, and social connectedness. CONCLUSION We identified several psychosocial themes that clinical team members believe impact the transition of patients with childhood-onset SLE into adult care. The role of parental modeling, youth resilience, mental health and emotional care, improved childhood-onset SLE education, and structured peer support and social connectedness are highlighted, which may be amenable to interventions.
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Affiliation(s)
| | - Justin Kramer
- University of Texas Southwestern Medical Center, Dallas
| | | | - E Blair Solow
- University of Texas Southwestern Medical Center, Dallas
| | - Tracey Wright
- University of Texas Southwestern Medical Center and Texas Scottish Rite Hospital for Children, Dallas
| | - Una E Makris
- University of Texas Southwestern Medical Center and Veterans Administration North Texas Health Care System, Dallas
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Abstract
BACKGROUND The coexistence of inflammatory myositis in systemic lupus erythematosus (SLE) has not been extensively studied. In this study, we describe the incidence, distinct types of inflammatory myositis, and risk factors for this finding in a cohort of pediatric and adult SLE patients. METHODS We identified SLE patients with coexisting myositis followed between 2010 and 2019 at two pediatric hospitals and one adult hospital. Demographic, clinical, laboratory, and pathological features of myositis were collected, and descriptive statistics were applied. RESULTS A total of 1718 individuals were identified as having SLE (451 pediatric and 1267 adult patients). Of these, 108 were also diagnosed with inflammatory myositis (6.3%). People of black race had a significantly higher prevalence of inflammatory myositis, as did those with childhood-onset SLE compared to adult-onset disease. In the majority of patients (68%), SLE and inflammatory myositis presented concurrently. Overlapping features of systemic sclerosis occurred in 48%, while dermatomyositis-specific rashes were present in a third. Arthralgias and inflammatory arthritis were seen in >90%. Thrombotic events and significant pregnancy-related morbidity were present in more than a third of patients. Lymphopenia, hypocomplementemia, and a positive RNP were the most common laboratory features noted. Myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) were present in >40% of patients. A review of 28 muscle biopsy reports revealed a wide array of pathological features, including nonspecific changes, dermatomyositis, polymyositis, and necrotizing auto-immune myopathy. CONCLUSION In our SLE patient population, 6.3% presented with concurrent inflammatory myositis. Dermatomyositis-specific rashes, clinical features of systemic sclerosis, arthralgias and arthritis, and cytopenias were common coexisting clinical manifestations. A high frequency of RNP, MSA, and MAA were found. People of black race and with childhood-onset disease had a higher prevalence of myositis. Our findings suggest that SLE patients of black race, with childhood-onset SLE, and who possess MSA or MAA should be routinely screened for myositis.
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Affiliation(s)
- Nicole Bitencourt
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA
| | - E Blair Solow
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA
| | - Tracey Wright
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA.,Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, Dallas, USA
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Doaty S, Bitencourt N, Harvey W, Kolasinski S, Solow EB. Advocacy 101: Engaging Rheumatology Fellows in Health Policy and Advocacy. Arthritis Care Res (Hoboken) 2019; 71:1141-1145. [DOI: 10.1002/acr.23749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 09/04/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Sarah Doaty
- Alaska Native Tribal Health Consortium Anchorage Alaska
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Pineda Bernal L, Bitencourt N, Batra K, Solow EB. Successful use of rituximab in granulomatosis with polyangiitis with aortic inflammation. Clin Exp Rheumatol 2019; 37 Suppl 117:144-147. [PMID: 30299239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/09/2018] [Indexed: 06/08/2023]
Abstract
Large-vessel inflammation, although rare, has been increasingly recognised as a complication of granulomatosis with polyangiitis (GPA) in recent years. The presentation is highly variable, ranging from an incidental finding to aortic dissection and rupture. Treatment has predominately consisted of a combination of cyclophosphamide and high dose corticosteroids with surgical intervention when indicated. We present the case of a 34-year-old male diagnosed with GPA after presenting with sinus and eye inflammation and the ensuing investigation revealed large vessel involvement that remarkably improved after 6 months of treatment with the combination of rituximab infusions, methotrexate and corticosteroids.
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Affiliation(s)
- Lucas Pineda Bernal
- Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Nicole Bitencourt
- Division of Rheumatic Diseases, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kiran Batra
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
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Abstract
Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.
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Affiliation(s)
- Nicole Bitencourt
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA
| | - Bonnie L Bermas
- Division of Rheumatic Diseases, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-8884, USA.
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