Systemic Lupus Erythematosus Hospitalizations Research Articles

Outcomes and Predictors of Inpatient Mortality for Marantic Endocarditis Complicating Systemic Lupus Erythematosus: Contemporary Nationwide Study From the United States.

Systemic lupus erythematosus (SLE) patients are susceptible to marantic endocarditis (ME) due to a hypercoagulable state. The literature regarding the epidemiology and outcomes of ME in SLE patients is limited. All patients ≥18 years who had SLE with and without ME between 2007 and 2019 were identified from the National Inpatient Sample in the United States (US). Predictors of inpatient mortality for SLE patients with ME were analyzed. Between 2007 and 2019, there were 508,818 hospitalizations for SLE, of which 785 (0.2%) had ME. Of SLE patients with ME, 33 (4.2%) died while hospitalized over the study period. On multivariate analysis, female sex (adjusted odds ratio (aOR), 95% confidence intervals: 24.72 (3.21, 190.27)), age <34 years (aOR: 6.81 (1.80, 25.79)), anemia (aOR: 3.41 (1.12, 10.40)), antiphospholipid syndrome (aOR: 13.50 (3.83, 47.64)), stroke complicating ME (aOR: 9.64 (3.24, 28.71)), and acute kidney injury (aOR: 3.74 (1.06, 13.20)) were all associated with increased inpatient mortality among SLE patients with ME (P < .05 for all). Between 2007 to 2019, ME occurred in 0.2% of SLE hospitalizations, with a 4.2% average inpatient mortality over the study period. Female sex, antiphospholipid syndrome, and stroke were most strongly associated with increased inpatient mortality.

Cryptogenic Organizing Pneumonia Is Associated With Increased Mortality Risk in Hospitalizations for Systemic Lupus Erythematosus (SLE): A National Inpatient Sample Analysis.

Background This study analyzed the incidence, characteristics, and mortality risk associated with cryptogenic organizing pneumonia (COP) among hospitalizations for systemic lupus erythematosus (SLE) with lung involvement. Methods Adult hospitalizations from the 2016-2020 nationwide inpatient sample were analyzed using relevantInternational Classification of Diseases (ICD)-10 codes for SLE with lung involvement (M32.13) and COP (J84.116). We compared baseline characteristics of individuals with SLE and COP to those of other lung involvements using Chi-square tests for categorical variables and the Wilcoxon rank sum test for continuous variables. A Cox proportional hazards model was used to assess the risk of developing COP in the pooled cohort of SLE patients. The impact of COP on SLE mortality was assessed using multivariate logistic regression adjusting forillness severity, baseline risk of mortality at admission, and patient- and hospital-level covariates. Results Of 40,356 admissions for SLE, 3,175 (7.9%) were due to lung involvement, with COP identified in 570 cases (17.9%). Compared with otherlung involvement in SLE, individuals with COP were significantly older (mean age: 65 vs. 44.3 years; p<0.001), mostly female (515; 90.4% vs. 2,305 males; 88.5%; p=0.572), had a greater baseline risk of mortality [diagnosis-related groups (DRG) major or extreme likelihood of dying: 360; 63.1% vs. 1,133; 43.5%; p<0.001], and had a higher prevalence of peripheral vascular disease (25; 4.4% vs. 39; 1.5%; p<0.001), and lower prevalence of lymphocytopenia (45; 7.9% vs. 359; 13.8%; p=0.001), and hypothyroidism (44; 7.8% vs. 357; 13.7%; p=0.001). Predictors of COP included female sex [adjusted hazard ratio (AHR): 1.46; 95% confidence interval (CI): 1.12-2.96; p=0.022]; hospitalizations occurring in the third quarter of the year (AHR: 1.37; 95% CI: 1.05-2.23; p=0.038); hospital stays of six days or longer (AHR: 1.71; 95% CI: 1.06-2.77; p=0.029); undergoing five or more procedures during the same hospitalization (AHR: 1.56; 95% CI: 1.26-3.56; p=0.041); coexisting lymphocytopenia (AHR: 1.92; 95% CI: 1.16-3.19; p=0.011); need for mechanical ventilation (AHR: 1.60; 95% CI: 1.48-3.93; p=0.049), presence of another autoimmune disorder (AHR: 1.37; 95% CI: 1.15-4.29; p=0.040), and being hospitalized at private, investor-owned hospitals (AHR: 2.62; 95% CI: 1.03-6.64; p=0.043). Mortality in SLE with lung involvement was correlated with age ≥ 60 years [hazard ratio (HR) (95% CI) 1.16 (1.05-1.56); p=0.012], coexisting lupus nephritis [HR (95% CI), 2.44 (2.04-3.49); p=0.031], cancer [HR (95% CI), 3.49 (2.19-5.79); p<0.001], liver disease [HR (95% CI), 9.82 (4.79-12.57); p<0.001]; immune deficiency [HR (95% CI), 2.22 (2.02-3.11); p=0.031], hypothyroidism [HR (95% CI), 4.67 (1.47-7.75); p=0.009], and high blood pressure [HR (95% CI), 3.15 (2.83-4.51); p<0.001]. In the multivariable analysis, COP remained significantly associated with an increased risk of mortality [AHR (95% CI), 1.43 (1.16-2.74); p=0.031]. The incidence of COP did not significantly impact hospitalization costs ($US 94,772 ± 14,759 vs. 95,982 ± 32,625; p=0.954) or length of stay (mean length of hospital stay: 8.3 vs.6.8 days; p=0.147). Conclusion Cryptogenic organizing pneumoniawas associated with 1% of all hospitalizations for SLE and 18% of cases involving lung complications in SLE. The presence of COP significantly increased the risk of mortality in SLE patients with lung involvement.

Hydroxychloroquine Dose and Hospitalizations for Active Lupus.

We sought to determine the impact of hydroxychloroquine (HCQ) dose on the risk of hospitalizations for systemic lupus erythematosus (SLE). We conducted a case-crossover study within an academic health system, including patients with SLE who used HCQ and had ≥1 hospitalization for active SLE between January 2011 and December 2021. Case periods ended in hospitalization for SLE, whereas control periods did not. The exposures were the average weight-based HCQ dose, categorized as ≤5 or >5 mg/kg/day, and non-weight-based HCQ dose, categorized as <400 or 400 mg/day, assessed during each six-month case or control period. Odds ratios (ORs) were calculated using conditional logistic regression and adjusted for prior disease activity, kidney function, glucocorticoid use, and other immunosuppressant use. Of 2,974 patients with SLE who used HCQ (mean age 36.5 years; 92% female), 584 had ≥1 hospitalization with primary discharge diagnosis of SLE. Of these, 122 had ≥1 hospitalization for active SLE while using HCQ and had ≥1 control period with HCQ use during the study period. Lower HCQ weight-based dose (≤5 vs >5 mg/kg/day) and non-weight-based dose (<400 vs 400 mg/day) were each associated with increased hospitalizations for active SLE (adjusted OR 4.20, 95% confidence interval [CI] 1.45-12.19, and adjusted OR 3.39, 95% CI 1.31-8.81). The use of lower doses of HCQ was associated with an increased risk of hospitalizations for active SLE. Although the long-term risk of HCQ retinopathy must be acknowledged, this must be balanced with the short-term and cumulative risks of increased SLE activity.

American College of Rheumatology White Paper: The Effects of Climate Change on Rheumatic Conditions-An Evolving Landscape and a Path Forward.

Increases in global temperatures and extreme weather events associated with climate change have complex yet poorly understood detrimental impacts on human health. We reviewed the current published literature on climate change-related effects and rheumatic conditions. To summarize our current understanding of the likely effects of climate change, including increased air pollution, on rheumatic disease, we searched the published, peer-reviewed English-language literature from January 2000 to December 2022. Articles were reviewed by a team of rheumatologists and clinical and translational science researchers. Systematic review articles were not included but informed additional literature searches. After extensive examination and adjudication, 88 articles met inclusion criteria and were selected for review. Much of the epidemiologic investigations assessed associations between air pollution and increased risk of development of rheumatoid arthritis, anti-citrullinated protein antibodies, flares of gout, and hospitalizations for systemic lupus erythematosus. Increased heat vulnerability was associated with higher odds of recurrent hospitalizations across rheumatic conditions. Mechanisms for observed associations are poorly understood but could include the effects of epigenetic changes, oxidative stress, and inflammatory cytokines. Studies had limitations, including restricted geography and populations studied without focus on historically marginalized communities at highest risk for adverse effects from pollution and climate change, the relative lack of mechanistic evaluations, and most with only indirect links to climate change. To date, the published literature lacks studies that directly examine effects of climate change on rheumatic diseases. Collaborative translational and epidemiologic research is needed to enhance our understanding and awareness in this area.

#1357 Regional and national hospitalization burden of lupus nephritis and systemic lupus erythematous in Spain

Abstract Background and Aims The regional epidemiology of Systemic lupus erythematosus (SLE) and lupus nephritis (LN) within the same country is poorly understood. Being a rare disease, its severity may be influenced by local expertise and treatment protocols, especially when healthcare systems are fragmented, like in Spain (17 different healthcare systems in 17 Autonomous Community (AACC), population range 319.796 to 8.472.407), resulting in potentially different levels of expertise in regional referral centers. Additional heterogeneity may derive from different specialists (rheumatology, internal medicine, nephrology) caring for SLE and LN. We aim to investigate the disease burden of SLE and LN in Spain and its AACC between 2019 and 2021, and to characterize factors that may influence this burden. Method The primary diagnostic data and average cost of SLE and NL hospitalization were extracted from the Minimum Basic Data Set (MBDS, Ministry of Health) that contains data from private and public hospitals. Sociodemographic data were obtained from the National Statistics Institute. Results From 2019 to 2021, there were 872 LN and 3612 SLE nationwide hospitalizations. Over 60% occurred in Andalucia, Catalonia, and Madrid, which account for 48% of Spanish population. Nationwide, the incidence of LN and SLE hospitalization was 1.44 and 4.59 per 100 000, respectively. However, regional variability was large, with a 3.7-fold difference for LN and a 7.3-fold difference for SLE between Madrid and Valencia, 2 of the more populated AACC. The median LN/SLE hospitalization ratio was 0.33. Relative risk for hospitalization, compared to the national mean, ranged in AACC from 0.37 (Baleares) to 2.55 (La Rioja) for LN and from 0.22 (Baleares) to 3.67 (Ceuta and Melilla) for SLE (Fig. 1A). Heterogeneity was larger at the provincial level where 10/50 provinces had significantly higher or lower relative risk than the national mean (Fig. 1B). The length of SLE/LN hospitalizations was very variable across specialties and AACC. There was a trend for shorter duration in Nephrology and longer in Internal Medicine for both LN and SLE. Nephrology was mainly responsible (76%) for LN hospitalization, with regional differences. For SLE hospitalization, Nephrology was also most commonly in charge. Heterogeneity was larger at the province level within the same AACC. The average All-Patient-Related (APR) cost per LN and SLE hospitalization episodes was €5254 and €4376, respectively, with significant geographical variability. Total annual hospitalization costs varied significantly among AACC, ranging from €8683 (Ceuta and Melilla) to €682512 (Catalonia) for LN and from €68361 (Ceuta and Melilla) to €2229456 (Madrid) for SLE. Adjusted per million population, total LN hospitalization cost ranged from €27920 (Baleares) to €179248 (La Rioja), and SLE cost from €91563 (Baleares) to €399693 (Ceuta and Melilla). When adjusted by €1000 of average household net income, the budget burden of LN hospitalization was highest in La Rioja (€5812 per €1000 of average household net income) and lowest in Baleares (€809 per €1000), while for SLE was highest in Murcia (€11186 per €1000) and lowest in Baleares (€2652 per €1000) (Fig. 2A,B). Conclusion In conclusion, the burden of LN and SLE hospitalization is heterogeneous across and within Spanish AACC, with large regional differences in the distribution of cases, costs and specialists who care for these patients. The analysis of these differences may contribute to benchmarking of best practices, decreasing clinical practice heterogeneity, optimizing care for SLE and LN and improving outcomes.

Trends in avascular necrosis and related arthroplasties in hospitalized patients with systemic lupus erythematosus and rheumatoid arthritis

ObjectiveAvascular necrosis (AVN) is a devastating complication often necessitating arthroplasty, particularly common in systemic lupus erythematosus (SLE). Limited research exists on arthroplasty trends since new steroid-sparing agents. We analyzed trends and characteristics associated with AVN and AVN-related arthroplasties among SLE and RA hospitalizations using two decades of data from the U.S. National Inpatient Sample (NIS). MethodsThis cross-sectional study used NIS (2000–2019) to identify hospitalized adults with SLE and RA, with or without AVN, using ICD codes. AVN was further grouped by arthroplasty status. Primary outcomes were AVN and AVN-related arthroplasty rates and time trends in SLE and RA. Baseline sociodemographics and comorbidities were compared. Analyses used STATA and Joinpoint regression to calculate annual percent change (APC). ResultsOverall, 42,728 (1.3 %) SLE and 43,600 (0.5 %) RA hospitalizations had concomitant AVN (SLE-AVN and RA-AVN). Of these, 16,724 (39 %) and 25,210 (58 %) underwent arthroplasties, respectively. RA-AVN increased (APC: 0.98*), with a decrease in arthroplasties (APC: -0.82*). In contrast, SLE-AVN initially increased with a breakpoint in 2011 (APC 2000–2011: 1.94* APC 2011–2019 -2.03), with declining arthroplasties (APC -2.03*). AVN hospitalizations consisted of individuals who were younger and of Black race; while arthroplasties were less likely in individuals of Black race or Medicaid coverage. ConclusionWe report a breakpoint in rising SLE-AVN after 2011, which may relate to newer steroid-sparing therapies (i.e., belimumab). AVN-associated arthroplasties decreased in SLE and RA. Fewer AVN-associated arthroplasties were noted for Black patients and those with Medicaid, indicating potential disparities. Further research should examine treatment differences impacting AVN and arthroplasty rates.

Incidence of Atrial Fibrillation and Related Outcomes among Hospitalized Patients with Systemic Lupus Erythematosus: Analysis of United States Nationwide Inpatient Sample Database 2016-2019.

Background: While patients with systemic lupus erythematosus (SLE) are known to have an increased risk of developing atrial fibrillation (AF), there is a scarcity of national population-based studies that evaluate the impact of AF on SLE. Methods: In this study, we use the 2016 to 2019 National Inpatient Sample (NIS) to determine the impact of AF on inpatient outcomes among adults hospitalized with systemic lupus erythematosus (SLE). Among a total of 41,004 SLE hospitalizations, 1495 (3.65%) patients had a concurrent diagnosis of AF. The baseline hospital and patient characteristics for both cohorts (SLE with AF and SLE without AF) were compared using the chi-square test and Student's t-test while univariate and multivariate regression analysis were used to calculate the unadjusted and adjusted odds ratios (aOR) for in-hospital outcomes for both cohorts. Results: Our data revealed that among SLE patients, AF was associated with higher in-hospital mortality (aOR 2.07), length of stay (9.03 days), and hospital costs (USD 100,190.50) along with increased incidence of non-ST-elevation myocardial infarction (NSTEMI) (aOR 2.79), pericardial effusion (aOR 2.38), cardiac tamponade (aOR 3.33), and cardiogenic shock (aOR 8.19). Conclusion: Our findings suggest that patients hospitalized with SLE and underlying AF may be at risk for poor clinical outcomes.

FRI045 Impact Of Morbid Obesity On Lupus Hospitalizations: A Nationwide Analysis

Abstract Disclosure: F. Sami: None. S. Sami: None. K.N. Patolia: None. T. Ayub: None. Background: Obesity is a risk factor for Systemic Lupus erythematosus(SLE) and reduces quality of life in SLE patients because of disease activity and damage accrual. We aim to define the epidemiology of obese SLE patients, impact of morbid obesity on lupus hospitalizations &amp; assess healthcare economic burden from obesity. Methods: The National Inpatient Sample (NIS) was used to obtain data. Data was optimized to reflect national estimates. Patients hospitalized with a principal diagnosis of SLE with and without morbid obesity as a comorbidity were obtained from 2016-2019 NIS. Epidemiological characteristics were analyzed. Primary outcomes of mortality, length of hospital stay (LOS), &amp; total hospital charges(THC) were compared for both groups. Univariate logistic analysis was used to identify confounders and adjusted odds ratio was calculated using the multivariate logistic regression model. Results: Of 721,090 SLE hospitalizations, 7.96% had obesity as a comorbidity. For obese SLE patients, mean age was significantly lower than nonobese SLE patients(51.94 years [SD 13.86] vs 52.55 years [SD 17.30]). There were significantly more females (93.1% vs. 88%), were from age group of 40-60 years (47.5% vs 36.3%), were caucasians (50.64% vs 48.62%) and blacks (34.5% vs 30.7%)Obesity was less frequent in Hispanic and Asian lupus patients (odds ratio [OR] 0.79 and 0.33, respectively). It was significantly more in low socioeconomic SLE patients (income $1-$55,999) (38.18% vs. 33.87%) and less prevalent in high socioeconomic class with income &amp;gt; $94000 (13.3% vs 49.56%). Mortality rate was significantly higher for obese SLE patients (1.54 % vs. 1.20%, OR 1.03). Obese group had mean LOS 5.79 days vs. 5.42 days (p-value 0.009) and higher THC ($66265 vs $63742, p-value &amp;lt; 0.001). Charlson comorbidity index was higher for obese SLE (3.33 vs 2.98, p-value &amp;lt; 0.001). Obese SLE patients were significantly more common to have sepsis (10.24% vs 8.67%, OR 1.20), heart failure (6.50% vs 5.05%, OR 1.31) pulmonary embolism/deep vein thrombosis (PE/DVT) (3.86% vs. 2.69%,OR 1.45) and respiratory failure (17.91% vs 12.68%, OR 1.50), with p-value &amp;lt; 0.001 for all.It was not an independent predictor of mortality for SLE patients. Other significant predictors of mortality identified for SLE patients were age (OR 1.02), Charlson comorbidity index (OR 1.06), renal failure (OR 2.75), sepsis (OR 2.74), PE/DVT (OR 2.22), respiratory failure (OR 12.75), and stroke (OR 1.82), most of which were more common with obesity. Conclusion: Obesity with SLE is more widely seen in females, relatively younger age, low socioeconomic class, Caucasians and African-Americans. Obese SLE patients have greater mortality, THC &amp; LOS, reflecting more healthcare burden. Respiratory failure, stroke, sepsis, PE/DVT and heart failure are more common in obese patients. Therefore, weight optimization therapies for SLE may improve outcomes. Presentation: Friday, June 16, 2023

Gender Disparities in Hospitalization Outcomes and Healthcare Utilization Among Patients with Systemic Lupus Erythematosus in the United States.

Background Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease characterized by various clinical manifestations. Despite efforts to improve outcomes, mortality rates remain high, and certain disparities, including gender, may influence prognosis and mortality rates in SLE. This study aims to examine the gender disparities in outcomes of SLE hospitalizations in the US. Methods We conducted a retrospective analysis of the Nationwide Inpatient Sample (NIS) database between 2016 and 2020. The NIS database is the largest publicly available all-payer database for inpatient care in the United States, representing approximately 20% of all hospitalizations nationwide. We selected every other year during the study period and included hospitalizations of adult patients (≥18 years old) with a primary or secondary diagnosis of SLEusing International Classification of Diseases, Tenth Revision (ICD-10) codes. The control population consisted of all adult hospitalizations. Multivariate logistic regression was used to estimate the strength of the association between gender and primary and secondary outcomes. The regression models were adjusted for various factors, including age, race, median household income based on patients' zip codes, Charlson comorbidity index score, insurance status, hospital location, region, bed size, and teaching status. To ensure comparability across the years, revised trend weights were applied as the healthcare cost and use project website recommends. Stata version 17 (StataCorp LLC, TX, USA) was used for the statistical analyses, and a two-sided P-value of less than 0.05 was considered statistically significant. Results Among the 42,875 SLE hospitalizations analyzed, women accounted for a significantly higher proportion (86.4%) compared to men (13.6%). The age distribution varied, with the majority of female admissions falling within the 30- to 60-year age range, while most male admissions fell within the 15- to 30-year age category. Racial composition showed a slightly higher percentage of White Americans in the male cohort compared to the female cohort. Notably, more Black females were admitted for SLE compared to Black males. Male SLE patients had a higher burden of comorbidities and were more likely to have Medicare and private insurance, while a higher percentage of women were uninsured. The mortality rate during the index hospitalization was slightly higher for men (1.3%) compared to women (1.1%), but after adjusting for various factors, there was no statistically significant gender disparity in the likelihood of mortality (adjusted odds ratio (aOR): 1.027; 95% confidence interval (CI): 0.570-1.852; P=0.929). Men had longer hospital stays and incurred higher average hospital costs compared to women (mean length of stay (LOS): seven days vs. six days; $79,751 ± $5,954 vs. $70,405 ± $1,618 respectively). Female SLE hospitalizations were associated with a higher likelihood of delirium, psychosis, and seizures while showing lower odds of hematological and renal diseases compared to men. Conclusion While women constitute the majority of SLE hospitalizations, men with SLE tend to have a higher burden of comorbidities and are more likely to have Medicare and private insurance. Additionally, men had longer hospital stays and incurred higher average hospital costs. However, there was no significant gender disparity in the likelihood of mortality after accounting for various factors.

Cancer development in patients hospitalized with systemic lupus erythematosus: A population-level data linkage study.

To explore the association between systemic lupus erythematosus (SLE) with the risk of cancer development and subsequent 5-year mortality in Western Australia (WA). Population-level, data linkage study of SLE patients (n = 2111) and general population comparators (n = 21 110) hospitalized between 1980 and 2014. SLE patients (identified by ICD-9-CM: 695.4, 710.0, and ICD-10-AM: L93.0, M32.0) were nearest matched (10:1) for age, sex, Aboriginality, and temporality. Follow up was from time zero (index SLE hospitalization) to cancer development, death or 31 December 2014. We assessed the risk of cancer development and subsequent 5-year mortality between SLE patients and comparators with univariate and multivariate-adjusted Cox proportional hazards regression models. SLE patients had similar multivariate-adjusted risk (adjusted hazard ratio [aHR] 1.03, 95% confidence interval [CI] 0.93-1.15; p = .583) of cancer development. Cancer development risk was higher in SLE patients <40 years old (aHR 1.58, 95% CI 1.29-1.94; p < .001), and from 1980 to 1999 (aHR 1.16, 95% CI 1.02-1.31; p < .001). SLE patients had higher risk of developing cancer of the oropharynx (aHR 2.13, 95% CI 1.30-3.50), vulvo-vagina (aHR 3.22, 95% CI 1.34-7.75), skin (aHR 1.20, 95% CI 1.01-1.43), musculoskeletal tissues (aHR 2.26, 95% CI 1.16-4.40), and hematological tissues (aHR 1.78 95% CI 1.25-2.53), all p < .05. After cancer development, SLE patients had increased risk of 5-year mortality (aHR 1.31, 95% CI 1.06-1.61); highest in patients <50 years old (aHR 2.03, 95% CI 1.03-4.00), and in those with reproductive system and skin cancers. Hospitalized SLE patients had increased risk of multiple cancer sub-types. Following cancer development, SLE patients had increased risk of 5-year mortality. There is scope to improve cancer prevention and surveillance in SLE patients. Not applicable. This low-risk risk study used de-identified administrative linked health data.

Characterizing primary hospitalizations for systemic lupus erythematosus in the United States.

Characterizing primary hospitalizations for systemic lupus erythematosus in the United States.

Longitudinal trends of systemic lupus erythematous hospitalizations in the United States: a two-decade population-based study.

Longitudinal data are limited on systemic lupus erythematosus (SLE) hospitalizations. We aim to study longitudinal trends of SLE hospitalizations in the last 2 decades in the United States (U.S). Data were obtained from the National Inpatient Sample database (NIS). We performed a 21-year longitudinal trend analysis of NIS 1998-2018. We searched for hospitalizations for adult patients with a "principal" diagnosis of SLE (SLE flare group) and those with "any" diagnosis of SLE (all SLE hospitalization group) using ICD codes. All non-SLE hospitalizations for adult patients were used as the control. Multivariable logistic and linear regression were used appropriately to calculate adjusted p-trend for the outcomes of interest. Incidence of SLE flare hospitalization reduced from 4.1 to 3.2 per 100,000 U.S persons from 1998 to 2018 (adjusted p-trend < 0.0001). The proportion of all hospitalized patients with SLE admitted principally for SLE reduced from 11.3% in 1998 to 5.7% in 2018 (adjusted p-tend < 0.0001). The proportion of hospitalized blacks in the SLE flare and all SLE hospitalization groups increased from 37.7% and 26.9% in 1998 to 44.7% and 30.7% in 2018 respectively (adjusted p-trend < 0.0001). The proportion of hospitalized Hispanics and Asians disproportionally increased in SLE flare hospitalizations compared to the control group. The incidence of hospitalization for SLE flare has reduced in the last 2 decades in the U.S. The proportion of hospitalized patients with SLE admitted principally for SLE has reduced significantly over time. However, the burden of SLE hospitalizations among ethnic minorities has increased over time. Key Points • The incidence of hospitalization for SLE flare has reduced in the last 2 decades in the U.S. • The proportion of hospitalized patients with SLE admitted principally for SLE has reduced significantly over time. • The burden of SLE hospitalizations among ethnic minorities such as blacks has increased over time.

Comparing two machine learning approaches in predicting lupus hospitalization using longitudinal data

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease characterized by flares ranging from mild to life-threatening. Severe flares and complications can require hospitalizations, which account for most of the direct costs of SLE care. This study investigates two machine learning approaches in predicting SLE hospitalizations using longitudinal data from 925 patients enrolled in a multicenter electronic health record (EHR)-based lupus cohort. Our first Differential approach accounts for the time dependencies in sequential data by introducing additional lagged variables between consecutive time steps. We next evaluate the performance of LSTM, a state-of-the-art deep learning model designed for time series. Our experimental results demonstrate that both methods can effectively predict lupus hospitalizations, but each has its strengths and limitations. Specifically, the Differential approach can be integrated into any non-temporal machine learning algorithms and is preferred for tasks with short observation periods. On the contrary, the LSTM model is desirable for studies utilizing long observation intervals attributing to its capability in capturing long-term dependencies embedded in the longitudinal data. Furthermore, the Differential approach has more options in handling class imbalance in the underlying data and delivers stable performance across different prognostic horizons. LSTM, on the other hand, demands more class-balanced training data and outperforms the Differential approach when there are sufficient positive samples facilitating model training. Capitalizing on our experimental results, we further study the optimal length of patient monitoring periods for different prediction horizons.

The effect of air pollution on systemic lupus erythematosus: A systematic review and meta-analysis.

Systemic lupus erythematosus (SLE) is an autoimmune disease resulting from impaired inflammatory responses. Given the role of air pollution on increasing inflammatory mediators, thus, we aimed to systematically review and meta-analyze evidence regarding an association between short-term exposure to air pollution and SLE onset, activity, and hospitalization. Electronic databases including Web of Science, PubMed, Scopus, and Embase were searched for all published articles until July 5, 2021. Newcastle Ottawa Scale (NOS) checklist was used to assess the quality of individual studies. Relevant demographic data and the intended results of the selected studies were extracted, and their adjusted risk ratios (RRs) were pooled using random and fixed effect analysis based on the heterogeneity index. Twelve studies were entered in our systematic review, and finally, six publications were enrolled in meta-analysis. Overall, Meta-analysis showed no significant association between an increase of PM2.5 on the third day and SLEDAI score with pooled adjusted RR of 1.212 (95% CI, 0,853-1.721), p-value = 0.284. However, there was a positive relationship between 6days increase of Particulate matter (PM) 2.5 and the systemic lupus erythematosus disease activity Index (SLEDAI) score (pooled adjusted RR 1.112; 95% CI, 1.005-1.231), p-value = 0.040. There was no significant association between carbon monoxide (CO), nitrogen dioxide (NO2), PM2.5, and PM10 increase in the air and hospitalization of SLE patients with pooled RR of 1.021 (95% CI, 0,986-1.1.057), p-value = 0.249, 1.034 (95% CI, 0.996-1.068); p-value = 0.079, 1.042 (95% CI, 0.994-1.092); p-value = 0.084 and 1.004 (95% CI, 0.996-1.013); p-value = 0.323, respectively. Also, analysis showed a significant relation between ozone (O3) increase and hospitalization with a pooled RR of 1.076 (95% CI, 1.009-1.147); p-value = 0.025. Finally, analysis of SO2 increase and risk of hospitalization demonstrated no significant relationship with the pooled RR of 1.011; (95% CI, 0.962-1.062), p-value = 0.0.671. Our findings prove that PM2.5 was associated with increased SLE risk. We also showed that only O3 was associated with increased hospital admissions of SLE patients.

Trends in all-cause hospitalizations for systemic lupus erythematosus in Mexico, 2000-2019.

Hospitalizations due to systemic lupus erythematosus (SLE) incur substantial resource use. Hospitalization trends provide a key benchmark of the disease burden. However, there is little long-term data in Mexico. Therefore, we evaluated Mexican hospitalization trends for SLE during 2000-2019. Hospitalization trends of SLE were studied using data from 2000 to 2019 releases of the National Dynamic Cubes of the General Direction of Health Information, which provides data on hospitalization discharges in Mexico. Patients aged ≥15 years hospitalized during the study period with a principal discharge diagnosis of SLE (ICD-10 code M32) were included. From 2000 to 2019, there were 17,081 hospitalizations for SLE, of which 87.6% were in females and 87% in subjects aged 15-44 years. From 2000 to 2019, the age-standardized hospitalization rate for patients with SLE increased from 0.38 per 100,000 persons to 0.65 per 100,000 persons with an average annual percentage change (APC) of 2.9% (95% CI 6.2-63.2). Although there was a significant uptrend from 2000 through 2011, there was a significant decline from 2011 to 2019 (APC: -4.8%, 95% CI -7.0% to -2.5%). Similar trends were identified in subjects aged 15-44 years and in both sexes. The length of stay and inpatient mortality decreased between 2000-2009 and 2010-2019. Although there was a substantial increase in SLE hospitalizations in 2000-2019, in 2011-2019, a decreased trend was reported in younger patients and in females and males. The length of stay was also reduced.

Exploration of machine learning methods to predict systemic lupus erythematosus hospitalizations.

Systemic lupus erythematosus (SLE) is a heterogeneous disease characterized by disease flares which can require hospitalization. Our objective was to apply machine learning methods to predict hospitalizations for SLE from electronic health record (EHR) data. We identified patients with SLE in a longitudinal EHR-based cohort with ≥2 outpatient rheumatology visits between 2012 and 2019. We applied multiple machine learning methods to predict hospitalizations with a primary diagnosis code for SLE, including decision tree, random forest, naive Bayes, logistic regression, and an ensemble method. Candidate predictors were derived from structured EHR features, including demographics, laboratory tests, medications, ICD-9/10 codes for SLE manifestations, and healthcare utilization. We used two approaches to assess these variables over longitudinal follow-up, including the incorporation of lagged features to capture changes over time of clinical data. The performance of each model was evaluated by overall accuracy, the F statistic, and the area under the receiver operator curve (AUC). We identified 1996 patients with SLE. 4.6% were hospitalized for SLE in their most recent year of follow-up. Random forest models had highest performance in predicting SLE hospitalizations, with AUC 0.751 and AUC 0.772 for two approaches (averaging and progressive), respectively. The leading predictors of SLE hospitalizations included dsDNA positivity, C3 level, blood cell counts, and inflammatory markers as well as age and albumin. We have demonstrated that machine learning methods can predict SLE hospitalizations. We identified key predictors of these events including known markers of SLE disease activity; further validation in external cohorts is warranted.

Predictors of hospitalization in patients with systemic lupus erythematosus: a 10-year cohort study.

Recognising systemic lupus erythematosus (SLE) patients at higher risk for hospitalization, aiming at developing tailored management strategies, may help minimize admissions and improve long-term health outcomes. Our study aimed to identify predictors for hospitalization in patients with SLE. Cohort study of SLE patients followed in a referral centre. All hospitalizations from study baseline up to 120months were identified, and the primary indication for admission was categorized as follows: (1) SLE disease activity; (2); infection; and (3) other conditions. Demographic, clinical, and laboratory parameters at baseline were sought as predictors of hospitalization for (i) any cause, (ii) disease activity, and (iii) infection using survival analysis with Kaplan-Meier curves and log-rank tests. Potential predictors were further tested using multivariate Cox proportional hazards regression models. We included 398 patients (median follow-up: 120months). The incidence rate of hospitalization was 17.7 per 100 patient-years. The most frequent indications for hospitalization were SLE disease activity (29.4%) and infection (23.4%). In multivariate analysis, male gender, age > 50years, antiphospholipid antibodies positivity (aPL), SLEDAI-2K > 5, organ damage, and prednisone daily dose (PDN) predicted hospitalization for any cause. SLEDAI-2K > 5, aPL, PDN, and IS medication predicted hospitalization for active SLE. Male gender, prior biopsy-proven lupus nephritis, aPL, organ damage, and ongoing treatment with high-risk IS predicted hospitalization for infection. Treatment with antimalarials was associated with a lower risk of hospitalization for any cause and for infection. Positive aPL identifies SLE patients presenting a higher risk of hospitalization, while medication with antimalarials was associated with a lower risk. Key Points • Positive aPL is predictive of hospitalization for any medical condition, disease activity, and infection • Organ damage is predictive of hospitalization for any condition and infection • Antimalarials are predictive of a lower risk of hospitalization for any condition and infection.

Predictors of Unsuccessful Hydroxychloroquine Tapering and Discontinuation: Can We Personalize Decision-Making in Systemic Lupus Erythematosus Treatment?

ObjectiveHydroxychloroquine (HCQ) is a key systemic lupus erythematosus (SLE) drug, making concerns of drug shortages grave. Our objective was to evaluate factors associated with poor outcomes after HCQ taper or discontinuation in SLE.MethodsWe studied 5 Canadian SLE cohorts between 1999 and 2019, following patients from the date of HCQ tapering (cohort 1) or discontinuation (cohort 2). A composite outcome was defined as any of the following: a need for therapy augmentation, an increase (of at least 4 points) in the Systemic Lupus Erythematosus Disease Activity Index 2000 score, or hospitalization for SLE. In each cohort, multivariable Cox regression was used to identify demographic and clinical factors associated with time to the earliest of these events. A third cohort continuing to receive HCQ was also studied, to assess whether the same factors influenced the outcome even when the HCQ dose was unchanged.ResultsThe poor outcome rate, per 100 person‐years, was 35.7 (95% confidence interval [95% CI] 31.6–40.3) in the HCQ taper cohort (n = 398), 29.0 (95% CI 25.5–33.0) in the discontinuation cohort (n = 395), and 16.1 (95% CI 13.2–19.6) in the maintenance cohort (n = 395). In patients tapering HCQ, baseline prednisone use was independently associated with greater risk of poor outcomes. In the discontinuation cohort, the risk of poor outcomes was greater for Black patients and those diagnosed with SLE at age ≤25 years. Among those maintaining HCQ, baseline immunosuppressive use and First Nations ethnicity were associated with poor outcomes.ConclusionWe identified demographic and clinical factors associated with poor outcomes after HCQ taper/discontinuation. This information is critical in the current setting of potential shortages, but over the long term, such information could inform personalized therapies.

Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome as Risk Factors for Acute Coronary Syndrome in Young Patients: Analysis of the National Inpatient Sample.

This study aimed to compare the odds of acute coronary syndrome (ACS) in patients aged 18 to 40 years to patients older than 40 years with and without secondary diagnoses of systemic lupus erythematosus (SLE) or antiphospholipid antibody syndrome (APLS) while controlling for traditional cardiovascular (CV) risk factors. Data were extracted from the National Inpatient Sample database from 2016 to 2018. The National Inpatient Sample was searched for hospitalizations of adult patients with ACS as the principal diagnosis, with and without SLE or APLS as secondary diagnoses. Age was divided categorically into 2 groups: adults aged 18 to 40 years and those older than 40 years. The primary outcome was the development of ACS. Multivariate logistic regression analyses were used to adjust for confounders. There were 90,879,561 hospital discharges in the 2016 to 2018 database. Of those, 55,050 between the ages of 18 to 40 years and 1,966,234 aged older than 40 years were hospitalized with a principal diagnosis of ACS. Traditional CV risk factors were associated with ACS hospitalizations in both age groups. In multivariate analysis of the 18 to 40 years age group, both SLE (odds ratio, 2.18; 95% confidence interval, 1.814-2.625) and APLS (odds ratio, 2.18; 95% confidence interval, 1.546-3.087) were strongly associated with ACS hospitalizations. After the age of 40 years, there were no increased odds of ACS hospitalizations for SLE or APLS. In the younger population, SLE and APLS were strongly associated with ACS hospitalizations in addition to the traditional CV risk factors. In the older age group, traditional CV risk factors dominated and diluted the effect of SLE and APLS.

Causes of Hospitalization for Systemic Lupus Erythematosus in Saudi Arabia Compared With the Global Setting: A Retrospective Single-center Observational Study.

Background: This study sought to evaluate the main causes of hospitalization of patients with systemic lupus erythematosus (SLE) in a tertiary health center in Saudi Arabia.Methods: A retrospective observational study was performed for all the SLE patients admitted to King Saud Medical City between 2016 and 2019. The primary reason for hospitalization was determined by the primary physician caring for the patient at the time of admission.Results: Of the 98 hospitalizations for SLE, 49% of patients were admitted from the emergency department (ED) and 51% from the rheumatology clinic. The most common reason for hospitalization was lupus flare (68.4%) followed by infection (20.4%). The lupus flare patients commonly presented with musculoskeletal (MSK)symptoms (34.6%), renal manifestations (25.5%), and skin rash (24.5%), whereas patients admitted with infection were commonly diagnosed with community-acquired pneumonia (12.2%). Other hospitalization causes were obstetric complications, adverse drug reactions, and thrombosis. Intensive care unit (ICU) admission was necessary for 7% of patients due to acute respiratory distress syndrome (ARDS) and pulmonary hemorrhage (28.6%) or other reasons (14.1%), such as pleural effusion, cardiac tamponade, and thrombotic thrombocytopenic purpura (TTP).Conclusions: The two most common reasons for SLE hospitalization were lupus flare and infection. Lupus flare was mainly due to MSK, renal, and dermatologic manifestations. The most common infection leading to hospitalization was community-acquired pneumonia, and ICU admission was mainly due to ARDS and pulmonary hemorrhage.