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Objective: Racial/ethnic minorities experience more severe outcomes of coronavirus disease 2019 (COVID-19) in the general US population. This study was undertaken to examine the association between race/ethnicity and COVID-19 hospitalization, ventilation status, and mortality in people with rheumatic disease., Methods: US patients with rheumatic disease and COVID-19 were entered into the COVID-19 Global Rheumatology Alliance physician registry between March 24, 2020 and August 26, 2020 were included. Race/ethnicity was defined as White, African American, Latinx, Asian, or other/mixed race. Outcome measures included hospitalization, requirement for ventilatory support, and death. Multivariable regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) adjusted for age, sex, smoking status, rheumatic disease diagnosis, comorbidities, medication use prior to infection, and rheumatic disease activity., Results: A total of 1,324 patients were included, of whom 36% were hospitalized and 6% died; 26% of hospitalized patients required mechanical ventilation. In multivariable models, African American patients (OR 2.74 [95% CI 1.90-3.95]), Latinx patients (OR 1.71 [95% CI 1.18-2.49]), and Asian patients (OR 2.69 [95% CI 1.16-6.24]) had higher odds of hospitalization compared to White patients. Latinx patients also had 3-fold increased odds of requiring ventilatory support (OR 3.25 [95% CI 1.75-6.05]). No differences in mortality based on race/ethnicity were found, though power to detect associations may have been limited., Conclusion: Similar to findings in the general US population, racial/ethnic minorities with rheumatic disease and COVID-19 had increased odds of hospitalization and ventilatory support. These results illustrate significant health disparities related to COVID-19 in people with rheumatic diseases. The rheumatology community should proactively address the needs of patients currently experiencing inequitable health outcomes during the pandemic., (© 2020, American College of Rheumatology.)

Objective: There is emerging evidence that COVID-19 disproportionately affects people from racial/ethnic minority and low socioeconomic status (SES) groups. Many physicians across the globe are changing practice patterns in response to the COVID-19 pandemic. We sought to examine the practice changes among rheumatologists and what they perceive the impact to be on their most vulnerable patients., Methods: We administered an online survey to a convenience sample of rheumatologists worldwide during the initial height of the pandemic (between 8 April and 4 May 2020) via social media and group emails. We surveyed rheumatologists about their opinions regarding patients from low SES and racial/ethnic minority groups in the context of the COVID-19 pandemic. Mainly, what their specific concerns were, including the challenges of medication access; and about specific social factors (health literacy, poverty, food insecurity, access to telehealth video) that may be complicating the management of rheumatologic conditions during this time., Results: 548 rheumatologists responded from 64 countries and shared concerns of food insecurity, low health literacy, poverty and factors that preclude social distancing such as working and dense housing conditions among their patients. Although 82% of rheumatologists had switched to telehealth video, 17% of respondents estimated that about a quarter of their patients did not have access to telehealth video, especially those from below the poverty line. The majority of respondents believed these vulnerable patients, from racial/ethnic minorities and from low SES groups, would do worse, in terms of morbidity and mortality, during the pandemic., Conclusion: In this sample of rheumatologists from 64 countries, there is a clear shift in practice to telehealth video consultations and widespread concern for socially and economically vulnerable patients with rheumatic disease., Competing Interests: Competing interests: SI receives grant funds from the National Institute of Arthritis and Musculoskeletal and Skin Diseases; SMG grants and personal fees from Novartis—consulting/research support, Pfizer—consulting/research support, BMC Musculoskeletal Disorders—editorial board and Horizon—research support; DJ-K owns stocks in the following companies: Cytodyn, Walgreens, AstraZeneca. All other authors have declared that no competing interests exist., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Whilst immune-mediated adverse drug reactions (ADRs) are rare, they are potentially life-threatening and present a major problem for clinicians. The underlying mechanisms that cause ADRs are not fully understood although genomewide association studies (GWAS) and case-control investigations have associated human leucocyte antigen (HLA) alleles as risk factors. There is evidence that a patient's ethnic background can have an impact on their risk of developing an ADR. This review summarizes the evidence related to HLA alleles and ADRs with particular focus on patient ethnicity. Our analysis indicated that many of the alleles which have been associated with ADRs are found at higher frequencies in Asian populations. The data also showed that many of the alleles that are reported to be statistically significantly associated with ADRs are in linkage disequilibrium with each other and that they form haplotypes specific to certain ethnicities indicating at least some of the allele associations may not be causal., (© 2017 John Wiley & Sons Ltd.)

Objectives: Studying the characteristics of resilience may help to explain how, in the face of a chronic disease, people are able to cope in productive and effective ways. The Wagnild and Young Resilience Scale (RS) is an appropriate instrument to study resilience and has already been translated from the original English version into several languages. The aim of this study was to validate the Italian version of the RS, a 25-item scale ranging from 25 to 175 where higher scores indicate stronger resilience., Methods: The Minimal Translation Criteria were followed to translate the scale which was then filled out by 1090 students to assess the reliability, stability, internal consistency and concurrent validity., Results: Time stability was assessed in a sample of 117 students (M age=20.18 yr, SD 1.25) by test-retest correlation (r=0.78). RS reliability was evaluated in a second sample of 973 students (M age=16.95 yr, SD 1.50) with RS mean of 126.6 (SD 17.4). Concurrent validity was assessed by correlation with General Health Questionnaire (r=-0.51), Ego-Resilience Scale (r=0.63) and Beck Depression Inventory (r=-0.45). Internal consistency was evaluated by Cronbach alpha (α=0.84). Principal component analysis was performed on 24 out of the 25 items and resulted in six components., Conclusions: Our data indicated that the 24-item Italian version of the RS scale can be considered a useful instrument to measure resilience and can be used by healthcare staff to help patients cope effectively with stressful situations such as rheumatic and other chronic diseases.

Objective: To examine whether there is an association between country of birth in first-generation immigrants and first hospitalization for a rheumatic disease, and to study whether any such association remains in second-generation immigrants., Methods: In this followup study, the Swedish MigMed database at the Karolinska Institute in Stockholm was used to identify all primary hospital diagnoses of rheumatic diseases in first- and second-generation immigrants in Sweden between January 1, 1964 and December 31, 2004. Incidence ratios, standardized with regard to age, geographic region, and socioeconomic status, were estimated by sex in first- and second-generation immigrants., Results: First-generation immigrants from Iraq had a higher risk of rheumatoid arthritis than did subjects in the native-born Swede reference group, and the risk of systemic lupus erythematosus was increased in immigrants from Iraq and Africa; these raised risks persisted in the second generation. The lower risk of rheumatoid arthritis in some first-generation immigrants disappeared in the second generation. In groups of second-generation immigrants, the risk of ankylosing spondylitis was similar to the risk in the corresponding parental groups. Polish-born immigrants and second-generation Yugoslavs and Russians showed a significantly increased risk of systemic sclerosis. The raised risk of systemic sclerosis did not persist in the second generation, but was clustered in groups involved in certain blue collar occupations., Conclusion: Country of birth affected the risk of rheumatic disease. These findings indicate that both genetic and environmental factors are involved in the etiology of specific rheumatic diseases.

Objective: Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used and frequently lead to serious adverse events. Little is known about NSAID-related ethnic/racial disparities. We focused on differences in patient NSAID risk awareness, patient-doctor NSAID risk communication, and NSAID risk-avoidance behavior., Methods: We performed a cross-sectional analysis of survey data from the Alabama NSAID Patient Safety Study. Eligible patients were > or = 65 years old and currently taking prescription NSAIDs (Rx NSAIDS). Generalized linear latent and mixed models accounted for nesting of patients within physicians., Results: Of all 404 participants, 32% were African American and 73% were female. The mean +/- SD age was 72.8 +/- 7.5 years, and 64% reported an annual household income <$20,000. African American patients were less likely than white patients to recognize any risk associated with over-the-counter (OTC) NSAIDs (13.3% versus 29.3%; P = 0.001) and Rx NSAIDs (31.3% versus 49.6%; P = 0.001), report that their doctor discussed possible NSAID-related gastrointestinal problems (38.0% versus 52.4%; P = 0.007), and take medications to reduce ulcer risk (30.5% versus 50.2%; P = 0.001). Patients with lower income and education reported significantly less risk awareness for OTC and Rx NSAIDs. Racial/ethnic differences persisted after adjusting for multiple confounders., Conclusion: In this community-based study of low income elderly individuals receiving NSAIDs, we identified important racial/ethnic differences in risk awareness, communication, and behavior. Additional efforts are needed to promote safe NSAID use and reduce ethnic/racial disparities.

Objective: To investigate cognitive appraisal-adjustment relationships in Native American (NA) and Caucasian parents of children diagnosed with juvenile rheumatic diseases., Methods: NA (n = 16) and Caucasian (n = 24) parents completed measures of disease status, illness intrusiveness, and adjustment; the rheumatologist provided estimates of disease severity., Results: Hierarchical regression analysis revealed a moderating effect for racial group membership on the illness intrusiveness-parent adjustment relationship. Specifically, parent-perceived illness intrusiveness was more closely related to poorer adjustment among NA parents relative to Caucasian parents. Post hoc tests indicated that illness intrusiveness was significantly associated with poorer adjustment in NA parents, but was unrelated to parent adjustment in the Caucasian sample., Conclusions: Results highlight the importance of examining racial group differences in cognitive appraisal-adjustment outcome relationships. Results are discussed with respect to the need for incorporating cultural issues into pediatric chronic illness research and treatment.

Background: Hypovitaminosis D continues to be a problem for South Asian people living in the UK. This study investigates the association between widespread unexplained pain and biochemical osteomalacia in this group of people., Methods: All South Asian patients attending with unexplained widespread pain (CWP) over a two-year period had biochemical tests for osteomalacia: calcium, phosphate, alkaline phosphatase, vitamin D (25OHD), and parathyroid hormone (PtH). For comparison, a control group consisted of patients in whom a specific rheumatic diagnosis (SRD) had been made. A follow up questionnaire was sent enquiring about pain, disability and dietary habits. A small proportion of the responders attended for a further set of biochemical tests for osteomalacia., Results: The majority of patients in both groups had a raised PtH (124/220, 57%) and a low 25OHD (117/160, 73%). Where data on both PtH and 25OHD were available, 47% (64/137) had a combination of reduced 25OHD and raised PtH. Few of these patients had abnormal calcium, phosphate or alkaline phosphates. From the postal questionnaire the prevalence of disability and continuing pain was high in both groups, with the majority of respondents complaining of difficulty with activities and nearly half needing help. Pain was widespread, the same or worse and graded above 7/10 for 69% and 78% of respondents in the CWP and SRD groups respectively. Overall, sixty one percent of respondents thought their gait pattern had changed in the last year. No significant differences were seen between respondents based on diagnosis (CWP or SRD), initial or subsequent PtH levels, or current calcium and vitamin D consumption. At the time of the second blood test, 52% of those with an elevated PtH on the first test now had a normal PtH value but 31% of those with a normal PtH first time had an elevated PtH., Conclusion: This observational study conducted in a rheumatology clinic in the north of England has shown high levels of biochemical osteomalacia in people of South Asian origin and high levels of persistent pain and disability, unrelated to diagnosis, biochemical status or treatment with calcium and vitamin D.

Objectives: This study aimed to determine the cross-cultural adaptation and validation of the Korean version of the EQ-5D in rheumatic conditions., Methods: Translation, back-translation and cognitive debriefing were performed according to the EuroQol group's guidelines. For validity, 508 patients were recruited and administered the EQ-5D, Short-Form 36 and condition-specific measures. Construct validity and sensitivity were evaluated by testing a-priori hypotheses. For reliability, another 57 patients repeated the EQ-5D at 1-week interval, and intra-class correlations (ICC) and kappa statistics were estimated. For responsiveness, another 60 patients repeated it at 12-week interval within the context of clinical trial, and standardized response mean(SRM) were calculated., Results: The cross-cultural adaptation produced no major modifications in the scale. The associations of the EQ-5D with the generic- and condition-specific measures were observed as expected in hypotheses: the higher EQ-5Dindex and EQ-5D(VAS) scores, the better health status by generic- or condition-specific measures, and the better functional class. The ICCs were 0.751 and 0.767, respectively, and kappa ranged from 0.455 to 0.772. The SRM were 0.649 and 0.410, respectively., Conclusion: The Korean EQ-5D exhibits good validity and sensitivity in various rheumatic conditions. Although its reliability and responsiveness were not excellent, it seems acceptable if condition-specific measures are applied together.

Aims: To estimate the burden of rheumatic disorders in the New Zealand population by calculating general-practice consultation rates--as well as the influence of age, gender, ethnicity, and small-area deprivation on these consultation rates., Methods: Cases were identified from the Royal New Zealand College of General Practitioners database using search-strings of typical words used in consultation notes (for each of 10 rheumatic disorders). Rates were calculated from a denominator of the number of people attending at least once over a 12-month period to any of 22 contributing general practices. The independent effect of age, sex, ethnicity, and small-area deprivation was modelled using multiple logistic regression., Results: Of 29,152 people attending their general practitioner, 20.4% consulted with a rheumatic disorder. Older people, males, people who lived in more deprived areas, and Europeans were more likely to consult with a rheumatic disorder. With all rheumatic disorders, age was a significant influence upon consultation--especially osteoarthritis, gout, osteoporosis, and joint surgery. Maori were more likely than Europeans to consult with gout, but they were slightly less likely to consult with back pain or regional pain disorders. Small-area deprivation had small influences upon people consulting with gout, regional pain, and back pain., Conclusions: Rheumatic disorders form a significant part of the workload of general practitioners and this is significantly influenced by local demographic factors. Most of these conditions seen in general practice are non-inflammatory and non-surgical. If a community-needs approach was taken, it is likely that the workload and associated costs would be even greater.

Background and Objective: The UK has a growing South Asian population. In the South Asian population of Bradford people appear to be less tolerant of disease-modifying anti-rheumatic drugs (DMARDs). One reason for this may be poor communication during patient education, which is generally designed for white North European people. Our objective was to obtain information on DMARDs that were used, the duration of their use and reasons for their discontinuation between ethnic groups., Methods: Retrospective data were obtained from the inception of a clinical database in August 1993 to July 2001 using 'DMARD' as the main search item; a total of 5479 DMARD prescriptions were represented in the data. A subset of the data so obtained was cross-checked against the patient records. Inaccuracies in start and stop dates prior to January 1997, together with other reasons (such as incomplete data), resulted in a final data set of 2356 drugs. The drugs had been given to 1391 patients. Overwhelmingly, the two main ethnic groups were North European (1191 patients) and South Asian (193 patients)., Results: The final data set was based on the following drugs: azathioprine (179); antimalarials (chloroquine and hydroxychloroquine) (407); corticosteroids (648); D-penicillamine (61); methotrexate (459); sulphasalazine (493); and sodium aurothiomalate (96). Survival analysis showed that age and drug type were important variables influencing the duration of time spent on a drug before discontinuation. For age, drug survival was better for the older age group [log rank test, chi2(3) = 29.1, P < 0.0001]. For drug, survival was best for steroids, followed in decreasing order by sulphasalazine, methotrexate, sodium aurothiomalate, azathioprine, antimalarials and D-penicillamine [chi2(6) = 99.3, P < 0.00001). For all drugs, the main ethnic groups differed, with a 12-month survival rate of drugs in the North European group of 0.742 (95% confidence interval 0.693-0.791) and the South Asian group of 0.665 (95% confidence interval 0.645-0.684) [log rank test, chi2(1) = 18.19, P < 0.00001]. As the two main ethnic groups differed with respect to age and drug type, further survival analysis adjusting for these variables confirmed a significant difference between the two ethnic groups. The main reasons for terminating the DMARD differed between the groups: people of South Asian origin were more likely to discontinue the drug because of rashes, lack of efficacy and worry about the potential side-effects of the drug., Conclusions: People of South Asian ethnic status terminate DMARD therapy sooner than North Europeans. The reasons for this difference are not clear but may concern problems with effective communication, cultural differences in attitudes to chronic illness or genetic polymorphisms in drug metabolism.

Objective: To measure the association between walking velocity and hip and knee flexion range, ethnic background, anthropometrics, comorbid pathologies, and coimpairments, in a sample of community-dwelling aged persons., Methods: To reach our objective, we used data from the San Antonio Longitudinal Study of Aging (SALSA), a population-based cohort of Mexican American and European American persons aged 64 to 79. By fitting hierarchical regression models, we measured the variance in the walking velocity over 50 feet explained by hip and knee flexion range, adjusting for the combined influence of demographic and anthropometric variables, coexistent pathologic conditions, impairments, and the examiners who conducted the assessments., Results: The average walking velocity among the 702 subjects for whom data were available was 73.6 meters per minute (range 20 to 121). Bivariate analyses revealed significant associations between walking velocity and age, sex, ethnic background, height, weight, presence of arthritis, diabetes mellitus, stroke, upper leg pain, peripheral vascular disease, left ventricular hypertrophy, and forced expiratory volume at 1 second. The correlation (r) between walking velocity and flexion range of the hip and knee were 0.40 and 0.35, respectively (P < or = 0.001 for each). Multivariate hierarchical models adjusting for demographic and anthropometric characteristics of the subjects, and examiner variation, revealed that hip and knee flexion range explained 6% of the variance in walking velocity. Adjusting for the presence of comorbid conditions and coimpairments reduced the variance attributable to hip and knee flexion range only slightly, to 5%., Conclusion: Hip and knee flexion range contribute significantly to walking velocity in the SALSA cohort of community-dwelling aged persons.

Objective: To determine how frequently herbal remedies are employed as alternative therapies in rheumatic diseases, and the historical justification for their use., Methods: We conducted a survey in 250 outpatients in the rheumatology clinic of a teaching hospital in México. We registered general demographic information and the previous use of herbal remedies for rheumatic conditions, how effective they were, and the presence of adverse effects during their use. We identified the herbs employed, and cross-checked them with medical texts from the 16th through the 18th centuries on the use of herbal remedies., Results: Of 250 surveyed patients, 126 (51%) had used herbal remedies for their rheumatic conditions. 63% of all users reported them to be effective for the purpose they had been prescribed. 12% reported adverse effects, none of them life-threatening. Being a user had no relation with the patients' formal education. Three patients did not answer the survey. We were able to identify 67 plants. One third of these are either prescribed for rheumatic conditions in the consulted bibliography, or else were used for the same purpose by ancient Mexican cultures., Conclusion: Herbal remedies are frequently used for rheumatic conditions. Some of them have an historical antecedent for their use in rheumatic conditions. They deserve a cautious evaluation as adjunctive therapies in rheumatic diseases.

Risk of systemic lupus erythematosus (SLE) is high in west Africans compared with Europeans, and risk of rheumatoid arthritis (RA) is high in Native Americans compared with Europeans. These differences are not accounted for by differences in allele or haplotype frequencies in the human leucocyte antigen (HLA) region or any other loci known to influence risk of rheumatic disease. Where there has been admixture between two or more ethnic groups that differ in risk of disease, studies of the relationship of disease risk to proportionate admixture can help to distinguish between genetic and environmental explanations for ethnic differences in disease risk and to map the genes underlying these differences.

Objective: To document the frequency and disease phenotype of various rheumatic diseases in the Australian Aborigine., Methods: A comprehensive review was performed of the archaeological, ethnohistorical, and contemporary literature relating to rheumatic diseases in these indigenous people., Results: No evidence was found to suggest that rheumatoid arthritis (RA), ankylosing spondylitis (AS), or gout occurred in Aborigines before or during the early stages of white settlement of Australia. Part of the explanation for the absence of these disorders in this indigenous group may relate to the scarcity of predisposing genetic elements, for example, shared rheumatoid epitope for RA, B27 antigen for AS. In contrast, osteoarthritis appeared to be common particularly involving the temporomandibular joint, right elbow and knees and, most probably, was related to excessive joint loading in their hunter gatherer lifestyle. Since white settlement, high frequency rates for rheumatic fever, systemic lupus erythematosus, and pyogenic arthritis have been observed and there are now scanty reports of the emergence of RA and gout in these original Australians., Conclusion: The occurrence and phenotype of various rheumatic disorders in Australian Aborigines is distinctive but with recent changes in diet, lifestyle, and continuing genetic admixture may be undergoing change. An examination of rheumatic diseases in Australian Aborigines and its changing phenotype may lead to a greater understanding of the aetiopathogenesis of these disorders.

The impact of environmental factors on the causation of rheumatoid arthritis (RA) is thought to be considerable. We explored this by comparing the prevalence of RA amongst Pakistanis living in England, where it is relatively high amongst ethnic English, and in Pakistan. The frequency of other rheumatic diseases was also compared. Information on 2056 adult Pakistanis in England and 4232 in Pakistan was obtained by house-to-house surveys using identical protocols. Positive respondents were examined by the same two clinicians in both countries. Rheumatic complaints increased with age and were more common in females in both communities. The standardized morbidity ratio (SMR) (95% CI) of RA in England was 2.1 (1.1-3.1) compared with Pakistan, a difference that was entirely attributable to females. The SMR (95% CI) for women was 3.0 (0.4-5.6) and for men 0.86 (-0.84 to 2.56). In Pakistan, there was a trend to more reporting of some but not all rheumatic complaints amongst the affluent segment of the population. This was increasingly apparent amongst those resident in England and the possibility of an impact of easier ascertainment amongst the more educated cannot be discounted. Low back pain was significantly more common in England. Furthermore, the colder climate was frequently invoked as a cause of more symptoms in England. Thus, several factors may have influenced the observation that RA is more common amongst Pakistanis in England compared with Pakistan. An environmental factor cannot be excluded. However, the frequency of non-specific musculoskeletal pain was similar. The regions of Pakistan from which the two populations were derived were also different and immunogenetic heterogeneity might also have contributed to the difference in RA prevalence.

Arthritis and other rheumatic conditions are among the most prevalent diseases in the United States, particularly for women and some racial/ethnic groups. In 1992, arthritis was the leading cause of disability and was associated with total direct and indirect costs of $64.8 billion; projections indicate that by 2020, arthritis will affect 59.4 million (18.2%) persons in the United States. Previous reports have documented marked differences in the prevalence rates of arthritis by age, sex, race, ethnicity, education, and body mass index (BMI). To examine the relative importance of these factors, CDC used data from the 1989-1991 National Health Interview Survey (NHIS) and a multivariate model to estimate the independent effect of each factor on self-reported arthritis. This report summarizes the results of that analysis, which indicate that a higher risk for arthritis is associated with older age, overweight, or obesity and that a lower risk is associated with being Asian/Pacific Islander or Hispanic or with having a higher education level.