Depression Risk in Young Adults With Juvenile‐ and Adult‐Onset Lupus: Twelve Years of Followup

Objective

To compare major depression risk among young adults with juvenile‐onset and adult‐onset systemic lupus erythematosus (SLE), and to determine demographic and health‐related predictors of depression.

Methods

Young adults with SLE ages 18–45 years (n = 546) in the Lupus Outcomes Study completed annual telephone surveys from 2002–2015, including assessment of depression using the Center for Epidemiologic Studies Depression Scale (CES‐D), and self‐report measures of sociodemographics and health characteristics. Juvenile‐onset SLE was defined as age <18 years at diagnosis (n = 115). Repeated‐measures analysis was performed to assess the risk for major depression (CES‐D ≥24) at any point in study, and logistic regression was used to assess for recurrent (present on ≥2 assessments) major depression.

Results

Major depression was experienced by 47% of the cohort at least once during the 12‐year study period. In adjusted analyses, juvenile‐onset SLE patients had an increased risk of having a major depressive episode (odds ratio [OR] 1.7 [95% confidence interval (95% CI) 1.0–2.7]) and recurrent episodes (OR 2.2 [95% CI 1.2–4.3]), compared to participants with adult‐onset SLE. Older age, lower educational attainment, and physical function, higher disease activity, and a history of smoking were associated with an increased depression risk. Juvenile‐onset SLE patients had a higher risk of major depression across all educational groups.

Conclusion

Young adults with SLE, particularly those with juvenile‐onset disease, are at high risk for major depression, which is associated with increased disease activity, poorer physical functioning, and lower educational attainment. Early depression intervention in young adults with SLE has the potential to improve both medical and psychosocial outcomes.

     

Comparative Effectiveness of Mycophenolate Mofetil for the Treatment of Juvenile‐Onset Proliferative Lupus Nephritis

Objective

Although juvenile‐onset proliferative lupus nephritis (PLN ) leads to significant morbidity and mortality, there is no clinical trials–based evidence to support the treatment effectiveness of any therapy for juvenile‐onset PLN . Marginal structural models enable us to estimate treatment effectiveness using observational data while accounting for confounding by indication.

Methods

We used prospectively collected data to examine the effect of mycophenolate mofetil (MMF ), compared to the use of other therapies, on the long‐term outcome of a juvenile‐onset PLN cohort (age at PLN onset <18 years). The major outcome variable was the estimated glomerular filtration rate (GFR ) using the revised Schwartz formula. Confounding by indication was corrected for marginal structural model.

Results

A total of 172 subjects with juvenile‐onset PLN , with a mean followup duration of approximately 4 years, were included. Overall, MMF was superior to other therapies, with a relative effect estimate for MMF of 1.06, i.e., 6% better estimated GFR on average (95% confidence interval 0.7, 11.3), corrected for potential confounding by indication. We found that beginning in year 4 there was a significant improvement in estimated GFR in the patients who were treated with MMF versus other therapies. This improvement was maintained until the end of the study.

Conclusion

MMF was more beneficial than other therapies in improving/maintaining long‐term renal function in patients with juvenile‐onset PLN up to a maximum followup of 7 years. This finding is consistent with evidence from adult PLN clinical trials.

     

Activation, Attention, and Visuospatial Learning in Adults With and Without a Family History of Alcoholism

While recent evidence shows visuospatial information processing deficits to be present in chronic alcoholics, it remains unclear whether such deficits are present prior to alcohol abuse in persons at risk for developing alcoholism. If present, it is also unclear whether the information processing mechanisms underlying these deficits are the same in alcoholics and persons at risk for alcoholism. This study investigated visuospatial information processing psychophysiological activation in adults with and without a family history of alcoholism. Thirty matched nonalcoholics served as participants. Fifteen persons were from families in which at least one biologic parent and one other relative had a history of alcoholism. Another group of 15 persons had no family history of alcoholism. In addition to displaying atypical patterns of learning-contingent physiological activation, participants with a family history of alcoholism displayed visuospatial learning that was significantly poorer than persons with no family history of alcoholism. The learning and physiological activation displayed by the participants with a family history of alcoholism were similar to those displayed by previously studied alcoholics using a similar learning task. The data suggest that visuospatial learning deficits may reflect an antecedent to, rather than a consequence of, chronic alcohol abuse.     

Clinical Characteristics of Alcoholism in Alcohol-Dependent Subjects With and Without a History of Alcohol Treatment

BACKGROUND: Most clinical alcohol research is carried out on alcoholics who are in treatment, usually inpatients. However, most alcohol-dependent men and women never enter treatment, and even fewer ever receive inpatient care. Thus, some generally accepted data on the clinical course of alcoholism, derived from treatment samples, might not generalize to the entire population of alcohol-dependent individuals. This article characterizes the clinical characteristics of alcohol dependence in three groups of alcoholics, based on their histories of treatment for alcohol problems: those without prior rehabilitation; those with only outpatient approaches or Alcoholics Anonymous (AA); and subjects with an inpatient experience. METHODS: Semistructured interviews were administered to 3572 DSM-III-R-defined alcohol-dependent subjects from the Collaborative Study on the Genetics of Alcoholism. The clinical patterns were compared across the three groups of alcoholics: Group 1, never-treated (n = 1582; 44%); Group 2, histories of outpatient or AA only (n = 399; 11%); and Group 3, at least one inpatient experience (n = 1591; 45%). RESULTS: A progression was shown from Groups 1 to 3 for more general life problems (e.g., unemployment, marital instability); higher rates of additional drug dependencies and psychiatric disorders; and more alcohol-related adverse events. Logistic regression analyses revealed that those with no prior treatment were more likely to be women, Caucasian, and employed, and to report a lower rate of divorce/separation, lower levels of alcohol intake, and fewer alcohol problems. Among those who received help, inpatient care was predicted by an opposite profile. CONCLUSIONS: These results indicate that studies using data from inpatient populations may give a skewed picture of the clinical characteristics of alcohol dependence.     

Mortality and Heart Failure Hospitalization Among Young Adults With and Without Cardiogenic Shock After Acute Myocardial Infarction

ObjectivesTo investigate risk factors and outcomes of cardiogenic shock complicating acute myocardial infarction (AMI-CS) in young patients with AMI.BackgroundAMI-CS is associated with high morbidity and mortality rates. Data regarding AMI-CS in younger individuals are limited.Methods and ResultsConsecutive patients with type 1 AMI aged 18–50 years admitted to 2 large tertiary-care academic centers were included, and they were adjudicated as having cardiogenic shock (CS) by physician review of electronic medical records using the Society for Cardiovascular Angiography and Interventions CS classification system. Outcomes included all-cause mortality (ACM), cardiovascular mortality (CVM) and 1-year hospitalization for heart failure (HHF). In addition to using the full population, matching was also used to define a comparator group in the non-CS cohort. Among 2097 patients (mean age 44 ± 5.1 years, 74% white, 19% female), AMI-CS was present in 148 (7%). Independent risk factors of AMI-CS included ST-segment elevation myocardial infarction, left main disease, out-of-hospital cardiac arrest, female sex, peripheral vascular disease, and diabetes. Over median follow-up of 11.2 years, young patients with AMI-CS had a significantly higher risk of ACM (adjusted HR 2.84, 95% CI 1.68–4.81; P < 0.001), CVM (adjusted HR 4.01, 95% CI 2.17–7.71; P < 0.001), and 1-year HHF (adjusted HR 5.99, 95% CI 2.04–17.61; P = 0.001) compared with matched non-AMI-CS patients. Over the course of the study, there was an increase in the incidence of AMI-CS among young patients with MI as well as rising mortality rates for patients with both AMI-CS and non-AMI-CS.ConclusionsOf young patients with AMI, 7% developed AMI-CS, which was associated with a significantly elevated risk of mortality and HHF.     

Low Blood Pressure Is Associated With Greater Risk for Cardiovascular Events in Treated Adults With and Without Apparent Treatment‐Resistant Hypertension

Apparent treatment‐resistant hypertension (aTRH) may confound the reported relationship between low blood pressure (BP) and increased cardiovascular disease (CVD) in treated hypertensive patients. Incident CVD was assessed in treated hypertensive patients with and without aTRH (BP ≥140 and/or ≥90 mm Hg on ≥3 medications or <140/<90 mm Hg on ≥4 BP medications) at three BP levels: 1: <120 and/or <70 mm Hg and <140/<90 mm Hg; 2: 120–139/70–89 mm Hg; and 3: ≥140 and/or ≥90 mm Hg. Electronic health data were matched to emergency and hospital claims for incident CVD in 118 356 treated hypertensive patients. In adults with and without aTRH, respectively, CVD was greater in level 1 versus level 2 (multivariable hazard ratio, 1.88 [95% confidence interval [CI], 1.70–2.07]; 1.71 [95% CI, 1.59–1.84]), intermediate in level 1 versus level 3 (hazard ratio, 1.32 [95% CI, 1.21–1.44]; 0.99, [95% CI, 0.92–1.07]), and lowest in level 2 versus level 3 (hazard ratio, 0.70 [95% CI, 0.65–0.76]; 0.58, [95% CI, 0.54–0.62]). Low treated BP was associated with more CVD than less stringent BP control irrespective of aTRH.     

Blood Pressure Control Provides Less Cardiovascular Protection in Adults With Than Without Apparent Treatment‐Resistant Hypertension

Hypertension control may offer less protection from incident cardiovascular disease (CVD_i) in adults with than without apparent treatment‐resistant hypertension (aTRH), ie, blood pressure uncontrolled while taking three or more antihypertensive medications or controlled to <140/<90 mm Hg while taking four or more antihypertensive medications. Electronic health data were matched to health claims for 2006–2012. Patients with CVD_i in 2006–2007 or with untreated hypertension were excluded, leaving 118,356 treated hypertensives, including 40,690 with aTRH, and 460,599 observation years. Blood pressure and medication number were determined by all clinic visit means from 2008 to CVD_i or end of study. Primary outcome was first CVD_i (stroke, coronary heart disease, heart failure) from hospital and emergency department claims. Controlling for age, race, sex, diabetes, chronic kidney disease, and statin use, hypertension control afforded less CVD_i protection in patients with aTRH (hazard ratio, 0.87; 95% confidence interval, 0.82–0.93) than without aTRH (hazard ratio, 0.69; 95% confidence interval, 0.65–0.74; P<.001). Strategies beyond hypertension control may prevent more CVD_i in patients with aTRH.