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OBJECTIVE Smoking has been associated with increased systemic lupus erythematosus (SLE) risk, but the biologic basis for this association is unknown. Our objective was to investigate whether women's smoking was positively associated with SLE-associated proinflammatory chemokines/cytokines (stem cell factor [SCF], B lymphocyte stimulator [BLyS], interferon-γ-inducible 10-kd protein [IP-10], and interferon-α); or negatively associated with antiinflammatory cytokine interleukin-10 (IL-10); and whether associations were modified by SLE-related autoantibody status. METHODS The Nurses' Health Study (NHS, n = 121,700) and NHSII (n = 116,429) cohorts were begun in 1976 and 1989. In 1988-1990 (NHS) and 1996-1999 (NHSII), ~25% of participants donated blood samples. We identified 1,177 women without SLE with banked samples, and we tested by enzyme-linked immunoassay (ELISA) for chemokines/cytokines as well as anti-Sm, anti-Ro/SSA, anti-La/SSB, and anti-RNP. Antinuclear antibodies (ANAs) were detected by HEp-2 cell indirect immunofluorescence, and anti-double-stranded DNA antibodies and were assayed by ELISA. Smoking was assessed until blood draw. Separate tobit and linear regression analyses, adjusted for potential confounders, modeled associations between smoking and log-transformed chemokine/cytokine concentrations. Analyses were stratified by autoantibody status. Effect estimates were calculated as ratios of geometric means expressed as percentage differences. RESULTS Among the 15% of current/recent versus 85% of past/never smokers, BLyS levels were 8.7% higher (P < 0.01) and were 24% higher (P < 0.0001) among those who were ANA positive. Current/recent smokers had IL-10 concentrations 46% lower (P < 0.01) than past/never smokers; each 10 pack-years of smoking was associated with a 17% decrease in IL-10 level (P < 0.001). Smoking was not associated with IP-10 or SCF. CONCLUSION Elevated BLyS and lower IL-10 levels among current smokers, particularly among ANA-positive women, may be involved in SLE pathogenesis.

OBJECTIVE Knowledge remains scarce regarding diet and systemic lupus erythematosus (SLE) risk. Our objective was to investigate 4 dietary quality scores and SLE risk overall and by anti-double-stranded DNA (anti-dsDNA) positive versus negative subtypes. METHODS We studied 79,568 women in the Nurses' Health Study (1984-2014) and 93,554 in the Nurses' Health Study II (1991-2013). Using validated food frequency questionnaires, we calculated 4 dietary scores: the 2010 Alternative Healthy Eating Index (AHEI-2010), the Alternative Mediterranean Diet Score (aMed), the Dietary Approach to Stop Hypertension (DASH), and the Empirical Dietary Inflammatory Pattern (EDIP). Incident SLE was confirmed by medical record review. Time-varying Cox regression models estimated pooled hazard ratios (HRs) and 95% confidence intervals (95% CIs) of SLE risk, overall and by anti-dsDNA, for cumulative average dietary quality score tertiles and individual AHEI-2010 components. RESULTS We identified 194 incident SLE cases. SLE risk was similar in women with the highest (versus lowest) dietary scores (AHEI-2010 HR 0.78 [95% CI 0.54-1.14], aMed HR 0.82 [95% CI 0.56-1.18], DASH HR 1.16 [95% CI 0.81-1.66], EDIP HR 0.83 [95% CI 0.57-1.21]). No association was demonstrated for anti-dsDNA+ or anti-dsDNA- SLE risk. Women in the highest (versus lowest) AHEI-2010 tertile of nut/legume intake had a decreased SLE risk (HR 0.59 [95% CI 0.40-0.87]). No association was demonstrated for other AHEI-2010 components and SLE risk. CONCLUSION We observed no association between long-term adherence to the AHEI-2010, aMed, DASH, or EDIP scores with SLE risk, suggesting a large effect of dietary quality on SLE risk is unlikely. However, potential reduction in overall SLE risk with high nut/legume intake warrants further investigation.

OBJECTIVE Exposure to psychosocial stressors may contribute to the onset of systemic lupus erythematosus (SLE) through dysregulation of the adaptive stress response. The present study was undertaken to assess the relationship of childhood physical and sexual abuse to risk of SLE among Black women. METHODS Using data from the Black Women's Health Study, we followed 36,152 women from 1995 through 2015 with biennial questionnaires. Women reported on exposure to abuse during childhood (up to age 11) in 2005. Self-reported cases of incident SLE were confirmed as meeting the American College of Rheumatology SLE classification criteria by medical record review. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for SLE among women exposed to physical or sexual abuse during childhood, controlling for potential confounders. RESULTS We confirmed 101 cases of incident SLE and identified patients who had completed questions on child abuse during 670,822 person-years of follow-up. Both physical and sexual abuse during childhood were associated with statistically significant increases in SLE incidence. The HR for SLE associated with ≥2 episodes of severe sexual abuse compared to no abuse was 2.51 (95% CI 1.29-4.85) after adjustment for alcohol consumption, smoking, body mass index, oral contraceptive use, age at menarche, and parental education. The multivariable-adjusted HR for SLE with ≥5 episodes of severe physical abuse was 2.37 (95% CI 1.13-4.99). CONCLUSION Our results suggest that sexual and physical abuse during childhood increase SLE risk during adulthood among Black women. Research is necessary both to confirm this finding and to understand potential mediating mechanisms.

OBJECTIVE Using a quality improvement approach, our objective was to integrate a treat-to-target approach for rheumatoid arthritis (RA) through routine electronic collection of patient-reported disease activity scores and a multidisciplinary learning collaborative for rheumatologists. METHODS RA patients completed a patient-reported outcome measure, the Routine Assessment of Patient Index Data 3 (RAPID3), at check-in. Nine rheumatologists and their patients were allocated to a learning collaborative intervention group focused on a treat-to-target approach and 13 were allocated to a control group. The primary outcome was documentation of a treat-to-target implementation score: disease activity score, disease activity score used in the medication change decision, the presence of a treatment target, and an indication of shared decision-making. A primary analysis of patient visits with medication changes was conducted using an interrupted time-series analysis. RESULTS We studied 554 individual rheumatology patients with 709 patient visits. Treat-to-target implementation scores among intervention rheumatologists (mean ± SD 44.6% ± 1.63%) were 12.4% higher than in the control group (mean ± SD 32.2% ± 1.50%; P < 0.0001). We observed differences in treat-to-target implementation score components, comparing intervention group to control group rheumatologists: disease activity score present, 77.2% versus 68.0% (P = 0.02); disease activity score used in the medication change decision, 45.2% versus 30.0% (P < 0.01); treatment target, 9.0% versus 0.4% (P < 0.01); and shared decision-making, 46.9% versus 30.0% (P < 0.01). Secondary analysis of patient visits with high RAPID3 scores found that medication changes were 54% less likely in the intervention versus control group (odds ratio 0.46 [95% confidence interval 0.27-0.79], P = 0.005). CONCLUSION This nonrandomized, interrupted time-series trial demonstrated a modest but significant impact of a learning collaborative intervention on rheumatologist documentation of a treat-to-target approach in RA.

Objectives Moderate alcohol consumption has been associated with decreased systemic lupus erythematosus risk, but the biologic basis for this association is unknown. We aimed to determine whether moderate alcohol consumption was associated with lower concentrations of systemic lupus erythematosus-associated chemokines/cytokines in an ongoing cohort of female nurses without systemic lupus erythematosus, and whether the association was modified by the presence of systemic lupus erythematosus-related autoantibodies. Methods About 25% of participants from the Nurses’ Health Study ( n = 121,700 women) and Nurses’ Health Study 2 ( n = 116,429) donated a blood sample; of these, 1177 women were without systemic lupus erythematosus at time of donation. Cumulative average and current (within 4 years) intakes of beer, wine or liquor were assessed from pre-blood draw questionnaires. Chemokine/cytokine concentrations (stem cell factor, B-lymphocyte stimulator, interferon-inducible protein-10, interferon-alpha, interleukin-10) and antibodies against dsDNA and extractable nuclear antigens were obtained using enzyme-linked immunosorbent assays. Antinuclear antibodies were detected by indirect immunofluorescence on HEp-2 cells. Results At blood draw, the women’s mean age was 56 years and 22% were antinuclear antibody positive; 36% were African-American. About half (46%) reported consuming 0–5 g/day of alcohol. Stem cell factor levels were 0.5% lower ( p 5 g/day had mean stem cell factor levels 7% lower ( p = 0.002) than non-drinkers. Other cytokines were not significantly associated with alcohol intake. Autoantibody status did not modify observed associations. Conclusion In this study of female nurses, moderate alcohol consumption was associated with lower stem cell factor levels, suggesting a plausible mechanism through which alcohol may lower systemic lupus erythematosus risk might be by decreasing circulating stem cell factor.

Objective Lupus is a chronic, autoimmune disease that disproportionately affects African Americans. We adapted the Centers for Disease Control and Prevention’s Popular Opinion Leader model to implement an intervention tailored for African American individuals that leverages an academic-community partnership and community-based social networks to disseminate culturally appropriate lupus education. Methods Academic rheumatologists, social scientists, and researchers in Boston, MA and Chicago, IL partnered with local lupus support groups, community organizations, and churches in neighborhoods with higher proportions of African Americans to develop curriculum and recruit community leaders with and without lupus (Popular Opinion Leaders; POLs). POLs attended four training sessions focused on lupus education, strategies to educate others, and a review of research methods. POLs disseminated information through their social networks and recorded their impact, which was mapped using a geographic information system framework. Results We trained 18 POLs in greater Boston and 19 in greater Chicago: 97% were African American, 97% were female; and the mean age was 57 years. Fifty-nine percent of Boston POLs and 68% of Chicago POLs had lupus. POLs at both sites engaged members of their social networks and communities in conversations about lupus, health disparities, and the importance of care. Boston POLs documented 97 encounters with 547 community members reached. Chicago POLs documented 124 encounters with 4083 community members reached. Conclusions An adapted, community-based POL model can be used to disseminate lupus education and increase awareness in African American communities. Further research is needed to determine the degree to which this may begin to reduce disparities in access to care and outcomes.

OBJECTIVE To investigate the impact and timing of smoking cessation on developing rheumatoid arthritis (RA) and serologic phenotypes. METHODS We investigated smoking cessation and RA risk in the Nurses' Health Study (NHS) (1976-2014) and the NHS II (1989-2015). Smoking exposures and covariates were obtained by biennial questionnaires. Self-reported RA was confirmed by medical record review for American College of Rheumatology/European League Against Rheumatism criteria. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for RA serologic phenotypes (all, seropositive, seronegative) according to smoking status, intensity, pack-years, and years since cessation. RESULTS Among 230,732 women, we identified 1,528 incident cases of RA (63.4% of which were seropositive) during 6,037,151 person-years of follow-up. Compared with never smoking, current smoking increased the risk of all RA (multivariable HR 1.47, 95% CI 1.27-1.72) and seropositive RA (HR 1.67, 95% CI 1.38-2.01) but not seronegative RA (HR 1.20, 95% CI 0.93-1.55). An increasing number of smoking pack-years was associated with an increased trend for the risk of all RA (P < 0.0001) and seropositive RA (P < 0.0001). With increasing duration of smoking cessation, a decreased trend for the risk of all RA was observed (P = 0.009) and seropositive RA (P = 0.002). Compared to recent quitters (

Background Obesity may influence systemic lupus erythematous (SLE) pathogenesis via stimulation of systemic inflammation, but the relationship between obesity and SLE risk is unclear. Past studies have predominantly assessed White women, while Black women have higher prevalence of both obesity and SLE. Methods We prospectively assessed the relationship between Body Mass Index (BMI, kg/m2) and incident SLE within the Black Women's Health Study (median age 38 at entry in 1995). Height and weight at age 18 and during follow-up were self-reported. We confirmed incident SLE cases by updated American College of Rheumatology criteria and collected covariates prospectively. Cox proportional hazards regression models, adjusted for potential confounders, estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for categories of updated BMI and risk of SLE, relative to BMI 20–24.9 (“normal” BMI). Secondary analyses investigated BMI at age 18, BMI in 1995 at cohort entry, cumulative updated BMI and “lagged” BMI (≥4 years prior to outcome window to address possible reverse causation). Results Adult obesity was not related to SLE risk: HR for BMI ≥30 (“obesity”) relative to normal BMI at ≥4 years prior to SLE diagnosis was 0.90 (95% CI 0.53–1.54). However, obesity at age 18 was associated with increased risk: HR 2.38 (95% CI 1.26–4.51) for ≥30 vs. normal BMI. Conclusions Among these Black women, obesity as a teenager was associated with increased SLE risk in adulthood. Further studies are necessary to understand the biologic mechanisms and windows of exposure for the relationship of obesity to SLE pathogenesis.

Objective.Exposure to severe stressors may alter immune function and augment inflammation and cytokine release, increasing risk of autoimmune disease. We examined whether childhood abuse was associated with a heightened risk of incident systemic lupus erythematosus (SLE).Methods.Data were drawn from the Nurses’ Health Study II, a cohort of US female nurses enrolled in 1989, followed with biennial questionnaires. We measured childhood physical and emotional abuse with the Physical and Emotional Abuse Subscale of the Childhood Trauma Questionnaire and sexual abuse with the Sexual Maltreatment Scale of the Parent-Child Conflict Tactics Scale, both administered in 2001. We identified incident SLE (≥ 4 American College of Rheumatology 1997 classification criteria) through 2015. We used multivariable Cox regression models to evaluate the association between childhood abuse and SLE, accounting for potential confounders (e.g., parental education, occupation, home ownership) and mediators [e.g., depression, posttraumatic stress disorder (PTSD)].Results.Among 67,516 women, there were 94 cases of incident SLE. In adjusted models, exposure to the highest versus lowest physical and emotional abuse was associated with 2.57 times greater risk of SLE (95% CI 1.30–5.12). We found that 17% (p < 0.0001) of SLE risk associated with abuse could be explained by depression and 23% (p < 0.0001) by PTSD. We did not observe a statistically significant association with sexual abuse (HR 0.84, 95% CI 0.40–1.77, highest vs lowest exposure).Conclusion.We observed significantly increased risk of SLE among women who had experienced childhood physical and emotional abuse compared with women who had not. Exposure to childhood adversity may contribute to development of SLE.

Objective Systemic lupus erythematosus (SLE) affects black women more frequently than other racial/gender groups. In past studies, largely consisting of white and Asian cohorts, cigarette smoking was associated with increased SLE risk, and moderate alcohol consumption was associated with decreased SLE risk. The aim of this study was to assess associations of smoking and alcohol consumption with the risk of incident SLE among black women, using data from a long-term, prospective, follow-up study. Methods The Black Women's Health Study enrolled 59,000 black women in 1995 and collected data on demographics, health status, and medical and lifestyle variables. Follow-up questionnaires that were given every 2 years identified incident disease and updated risk factors. Cases of incident SLE that met the American College of Rheumatology revised criteria for SLE as updated in 1997 were confirmed through medical record review. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CI) for associations of cigarette smoking and alcohol intake with incidence of SLE. Results A total of 127 incident SLE cases from 1995 to 2015 (mean age 43 years at diagnosis) were confirmed. Compared to never smokers, the risk of SLE among ever smokers was elevated, but not significantly (HR 1.45 [95% CI 0.97-2.18]). Risk was similar for current and past smoking and increased nonsignificantly with increasing pack-years. The HR was 0.71 (95% CI 0.45-1.12) for current drinking relative to never drinking, with a HR of 0.43 (95% CI 0.19-0.96) for ≥4 drinks/week. Conclusion Findings from this large study of SLE risk among black women are consistent with previous results from studies in other populations of increased risk of SLE associated with cigarette smoking and decreased risk with moderate alcohol consumption.

Objective Lupus nephritis (LN) increases the risks of end-stage renal disease (ESRD) and death, but these risks are difficult to estimate. Since complement factors play an essential role in the pathogenesis and are deposited in the kidneys as C1q and C3, we studied whether these deposits predict ESRD and death in patients with LN. Methods We collected demographic, clinical and pathological data from 183 adult patients with LN classes II–V diagnosed with a first native kidney biopsy. Pathological data included the localization and intensity of immunofluorescence staining of C1q and C3. We obtained dates of incident ESRD and death from the United States Renal Data System and National Death Index, respectively, and evaluated survival curves and hazard ratios for ESRD and death as a composite outcome and as separate outcomes. Results The presence and intensity of deposits of C1q and C3 in glomeruli, tubular walls and vascular walls differed between classes and were associated with known unfavourable prognostic factors, such as hypertension, hypoalbuminemia and hypocomplementemia. However, over a median follow-up of 7.5 years, their presence and intensity were associated with neither survival free of ESRD and death nor hazard ratios for ESRD and death. Conclusion Renal deposits of complement factors did not predict ESRD and death in patients with LN.

Complex treatment decisions in rheumatoid arthritis (RA) affect aspects of patients' physical, psychological and emotional well-being. We aimed to identify key attributes of patient-centered rheumatologic care for adults with RA through a qualitative study using patient focus group discussions in order to guide quality improvement efforts around optimisation of disease management.Patients with RA were recruited from a large academic medical centre rheumatology clinic and its affiliate sites over one month and allocated into focus groups led by an experienced moderator. Focus groups were held until thematic saturation was reached. Patients' responses were examined, categorised into themes, and codified independently by three reviewers. We extracted statements identifying common themes from transcripts.Thirteen patients with RA were recruited and allocated into three focus groups. Mean age was 59.1±10.1 years and average RA disease duration was 17.8 years. All participants had experience taking at least one disease-modifying anti-rheumatic drug (DMARD). Following reviewer analysis of patients' responses, six common themes about quality RA care were identified including: the role and use of self-management strategies, the clinical environment, the health care delivery process, attitudes towards medication, insurance and medication access issues, and the impact of disease on lifestyle.Themes uncovered in focus group discussions related predominantly to the clinical environment and patient-provider communication. These preliminary results identified the need to incorporate operational aspects of health care delivery into our assessment of the RA patient experience and formed the basis of a RA quality improvement programme targeting medication optimisation.

Background Interstitial fibrosis and tubular atrophy (IFTA) and vascular injury are frequent histologic features of lupus nephritis renal biopsies, but their clinical correlates and prognostic value are not well understood. This cohort study investigated demographic, clinical and laboratory characteristics, and outcomes, associated with IFTA and vascular injury in lupus nephritis. Methods Reports of all renal biopsies performed at an academic medical center (1990–2017) with WHO/ISN/RPS Class II-V lupus nephritis were reviewed. Demographics, clinical variables and labs at biopsy, treatment, and date of death were collected. Additional data from the U.S. Renal Data System (USRDS) provided dates of ESRD and death after ESRD. Multivariable regression analyses identified demographic and clinical factors associated with each histologic finding. Cumulative incidence functions and multivariable Cox proportional hazard models estimated the risk of progression to ESRD and death. Results Within 202 initial biopsies, IFTA was associated with the patient's SLICC/ACR damage index (without renal domain) and serum creatinine, and vascular injury was associated with serum creatinine in multivariable models. In Cox regression models adjusting for age, sex, race, serum creatinine, calendar year, and biopsy class, moderate/severe IFTA was associated with elevated ESRD (HRSD 5.18, 95% CI 2.53, 10.59) and death (HR 4.19, 95%CI 1.27, 13.81). After adjustment for age, sex and race, moderate/severe vascular injury was associated with ESRD (HRSD 2.13, 95% CI 1.21, 3.75) and but this relationship was not significant after adjustment for serum creatinine and calendar year. Conclusions IFTA is a strong predictor of ESRD and death, even in proliferative nephritis, and a risk factor for poor outcomes independent of class. Vascular injury is a strong predictor of prognosis, but not independent of serum creatinine and class. The prognostic value of these lesions calls for consideration when determining treatment for lupus nephritis.

OBJECTIVE: To investigate whether a dietary pattern derived using inflammatory biomarkers is associated with rheumatoid arthritis (RA) risk. METHODS: We prospectively followed 79,988 women in the Nurses’ Health Study (NHS, 1984–2014) and 93,572 women in the NHSII (1991–2013); incident RA was confirmed by medical records. Food frequency questionnaires (FFQ) were completed at baseline and approximately every 4 years. Inflammatory dietary pattern was assessed from FFQ data using the Empirical Dietary Inflammatory Pattern (EDIP), including 18 anti-/pro-inflammatory food/beverage groups weighted by correlations with plasma inflammatory biomarkers (interleukin-6, C-reactive protein, and tumor necrosis factor-α receptor 2). We investigated associations between EDIP and RA using Cox regression. RESULTS: We identified 1,185 incident RA cases over 4,425,434 person-years. EDIP was not associated with overall RA risk (p trend=0.21 across EDIP quartiles). Among women ≤55 years, increasing EDIP was associated with increased overall RA risk; HRs (95%CIs) across EDIP quartiles were: 1.00 (reference), 1.14 (0.86–1.51), 1.35 (1.03–1.77), and 1.38 (1.05–1.83; p for trend=0.01). Adjusting for BMI attenuated this association. Increasing EDIP was associated with increased seropositive RA risk among women ≤55 years (p for trend=0.04). There was no association between EDIP and RA among women >55 years (EDIP-age interaction: p=0.03). CONCLUSION: An inflammatory dietary pattern was associated with increased seropositive RA risk with onset ≤55 years old, and this association may be partially mediated through BMI.

This article describes three complicated cases in rheumatology and pregnancy. The first case elucidates the challenges in treating SLE in conjunction with pulmonary arterial hypertension, while the second case features an SLE-affected pregnancy with development of portal hypertension secondary to portal vein thrombosis related to APS. The third case is a pregnant woman with stable SLE who developed thrombotic microangiopathy caused by atypical haemolytic uraemic syndrome, and failed to improve despite multiple measures including biopsy and elective preterm delivery. There are grave and unique challenges for women with autoimmune disease, but adverse outcomes can sometimes be avoided with careful and multidisciplinary medical management. Pre-conception counselling with regard to medications and disease treatment should also include discussion of the advisability of pregnancy, which may be difficult for a patient, but present the best course for optimizing health outcomes.

Maternal obesity and gestational diabetes mellitus (GDM) are associated with obesity and diabetes risk in offspring. We tested whether maternal insulin resistance, which frequently coexists with GDM and obesity, could independently contribute to dysregulation of offspring metabolism. Female mice haploinsufficient for insulin receptor substrate-1 (IRS1-het) are hyperinsulinemic and insulin resistant during pregnancy, despite normal plasma glucose and body weight, and thus serve as a model of isolated maternal insulin resistance. Wild-type (WT) offspring of IRS1-het dams insulin resistance-exposed [IR-exposed] were compared with WT offspring of WT dams. Despite no differences in adiposity, male IR-exposed pups were glucose intolerant (P = 0.04) and hyperinsulinemic (1.3-fold increase, P = 0.02) by 1 month of age and developed progressive fasting hyperglycemia. Moreover, male IR-exposed pups challenged with high-fat diet exhibited insulin resistance. Liver lipidomic analysis of 3-week-old IR-exposed males revealed increases in the 16:1n7 fraction of several lipid classes, suggesting increased Scd1 activity. By 6 months of age, IR-exposed males had increased lipid accumulation in liver as well as increased plasma refed fatty acids, consistent with disrupted lipid metabolism. Our results indicate that isolated maternal insulin resistance, even in the absence of hyperglycemia or obesity, can promote metabolic perturbations in male offspring.