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Biomedical subjects

Sasha Bernatsky

Publications and source records attributed to Sasha Bernatsky.

At least 19 recordsLinked to original sources

A novel high-dimensional model for identifying regional DNA methylation QTLs.

Varying coefficient models offer the flexibility to learn the dynamic changes of regression coefficients. Despite their good interpretability and diverse applications, in high-dimensional settings, existing estimation methods for such models have important limitations. For example, we routinely encounter the need for variable selection when faced with a large collection of covariates with nonlinear/varying effects on outcomes, and no ideal solutions exist. One illustration of this situation could be identifying a subset of genetic variants with local influence on methylation levels in a regulatory region. To address this problem, we propose a composite sparse penalty that encourages both sparsity and smoothness for the varying coefficients. We present an efficient proximal gradient descent algorithm that scales to high-dimensional predictor spaces, providing sparse solutions for the varying coefficients. A comprehensive simulation study has been conducted to evaluate the performance of our approach in terms of estimation, prediction and selection accuracy. We show that the inclusion of smoothness control yields much better results over sparsity-only approaches. An adaptive version of the penalty offers additional performance gains. We further demonstrate the utility of our method in identifying regional mQTLs from asymptomatic samples in the CARTaGENE cohort. The methodology is implemented in the R package sparseSOMNiBUS, available on GitHub.

Humans↗

Antirheumatic drug use and the risk of acute myocardial infarction.

OBJECTIVE: To assess the risk of acute myocardial infarction (AMI) associated with the use of disease-modifying antirheumatic drugs (DMARDs) and other medications commonly used in rheumatoid arthritis (RA). METHODS: We conducted a nested case-control analysis within a cohort of subjects with RA, observed between 1999 and 2003, identified from the PharMetrics claims database. For each first AMI hospitalization identified during followup, 10 controls matched on sex, age, and time of study entry were randomly selected from the cohort. Conditional logistic regression was used to estimate the rate ratio (RR) of AMI associated with the current use of anti-RA therapy, as measured from dispensed prescriptions, after adjustment for AMI risk factors. RESULTS: The cohort included 107,908 subjects (average age 54 years at cohort entry). During followup, 558 AMI cases occurred (3.4 per 1,000 per year). AMI rate was significantly decreased with the current use of any DMARD (adjusted RR 0.80, 95% confidence interval [95% CI] 0.65-0.98). This effect was consistent across all DMARDs, including methotrexate (RR 0.81, 95% CI 0.60-1.08), leflunomide (RR 0.28, 95% CI 0.12-0.65), and other traditional DMARDs (RR 0.67, 95% CI 0.46-0.97), but not biologic agents (RR 1.30, 95% CI 0.92-1.83). AMI rate increased with the use of glucocorticoids (RR 1.32, 95% CI 1.02-1.72) but not with nonselective nonsteroidal antiinflammatory drugs (RR 1.05, 95% CI 0.81-1.36) or cyclooxygenase 2 (COX-2) inhibitors (RR 1.11, 95% CI 0.87-1.43). CONCLUSION: DMARD use is associated with a reduction in AMI risk in patients with RA. No risk increase was found with the COX-2 inhibitors in this population.

Aged↗

Risk for incident arterial or venous vascular events varies over the course of systemic lupus erythematosus.

OBJECTIVE: We describe the pattern of incidence of thrombovascular events after diagnosis of systemic lupus erythematosus (SLE) in a cohort of lupus patients. METHODS: Descriptive study of prospectively collected data using incidence rates of thrombovascular events and 95% confidence intervals (CI) calculated for predetermined periods of observation. Kaplan-Meier survival curves were plotted to estimate thrombovascular event-free survival. RESULTS: Among 426 individuals, person-years contributed were as follows: 399 persons and 4356.0 person-years for all events; 417 persons and 4691.9 person-years for arterial events; and 408 persons and 4846.6 person-years for venous events. The incidence of thrombovascular events was highest during the first year after SLE diagnosis (4.00, 95% CI 2.24-6.59) and after 20 years (ranging from 3.32, 95% CI 1.52-6.30, to 4.99, 95% CI 0.60-18.01), and was lowest between 1 and 5 years after SLE diagnosis (1.00, 95% CI 0.53-1.72). A similar pattern was observed for arterial events, while venous events showed a higher incidence rate only in the first 30 days after SLE diagnosis (12.06, 95% CI 3.29-30.87) and remained low afterwards. The probabilities of remaining event-free at 5, 10, and 15 years were as follows: 0.92, 0.85, and 0.78, respectively, for all thrombovascular events; 0.95, 0.88, and 0.82, respectively, for arterial events; and 0.98, 0.95, and 0.94, respectively, for venous events. CONCLUSION: Thrombovascular events occur throughout the course of lupus, with the highest risk of arterial or venous events in the first year after diagnosis, and the pattern of occurrence varying thereafter.

Adult↗

Dimensions of fatigue in systemic lupus erythematosus: relationship to disease status and behavioral and psychosocial factors.

OBJECTIVE: To characterize the experience of fatigue in patients with systemic lupus erythematosus (SLE) using a multidimensional assessment and to delineate contributors to physical and mental dimensions of fatigue. METHODS: Fatigue in 130 women with SLE was assessed using the Multidimensional Fatigue Inventory (MFI-20). Participants completed standardized questionnaires assessing sleep quality, depressed mood, social support, and leisure-time physical activity. A clinical examination determined disease activity, cumulative damage, and whether patients fulfilled American College of Rheumatology criteria for fibromyalgia (FM). A series of hierarchical multiple regressions were computed to identify contributors to physical and mental fatigue. RESULTS: Patients scored high on all 5 MFI-20 fatigue dimensions, with general fatigue and physical fatigue having the highest scores. A hierarchical multiple regression showed that greater disease damage and disease activity, the presence of FM, depressed mood, sleep disturbance, and less participation in leisure-time physical activity contributed to higher physical fatigue scores. The results of the second model found depressed mood to be the strongest determinant of mental fatigue. Disease-related variables were not associated with mental fatigue. CONCLUSION: Fatigue in SLE is multidimensional and multidetermined, with physical and mental aspects likely having different etiologies. A multidimensional assessment of fatigue in SLE is needed to tailor and optimize interventions aimed at alleviating fatigue.

Depressive Disorder↗

Lymphoma in a patient with systemic lupus erythematosus.

BACKGROUND: A 40-year-old woman with a 10-year history of systemic lupus erythematosus (SLE) presented with fever, lymphadenopathy and fatigue. Before that time, her SLE symptoms had been controlled with hydroxychloroquine, NSAIDs, and an occasional short course of moderate-dose prednisone. Two months before presentation, she experienced fevers ranging from 38.3 to 39.7 degrees C, but she had no specific symptoms that suggested local infection. INVESTIGATIONS: Physical examination, multiple blood cultures, and laboratory investigations that included the following tests: hemoglobin concentration; erythrocyte sedimentation rate; C-reactive protein level; serum lactate dehydrogenase level; aspartate aminotransferase level; alanine aminotransferase level; serum complement C3 and C4 levels; white-blood-cell count; platelet count; urinalysis; serum creatinine level; CT of the chest and abdomen; bone-marrow biopsy; serum electrophoresis; and tests for Epstein-Barr virus, cytomegalovirus, hepatitis B virus, hepatitis C virus, HIV-1, antinuclear antibodies, antibodies to Smith antigen, antibodies to double-stranded DNA, and antibodies to Ro and La. DIAGNOSIS: Stage IVB diffuse large B-cell lymphoma with marrow and liver involvement concurrent with SLE. MANAGEMENT: The patient promptly underwent chemotherapy, receiving three courses of 3 mg/m(2) vindesine on day 1, 1,500 mg/m(2) cyclophosphamide and 80 mg/m(2) doxorubicin on day 2, and 50 mg/m(2) prednisolone on days 1-5.

Adult↗

Malignancy and autoimmunity.

PURPOSE OF REVIEW: The association of cancer with autoimmune disease has been under investigation for several years. Reports have appeared suggesting increased cancer risk in autoimmune rheumatic diseases. Evidence has been accumulating recently in rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, and scleroderma/systemic sclerosis. This review focuses on recent publications regarding risk of cancer in these conditions. RECENT FINDINGS: Despite a lack of a strong association between rheumatoid arthritis and cancer overall, studies show an increased risk for the development of lymphoma in rheumatoid arthritis. There are data suggesting an increased risk for rheumatoid arthritis patients regarding lung cancer. In Sjogren's syndrome-related malignancies, most publications in the past year relate to non-Hodgkin's lymphomas, and suggest possible mechanisms driving the association. Data substantiate an increased risk of certain cancers in systemic lupus erythematosus; the risk appears to be most heightened for lymphoma. A recent cohort study examined cancer risk in scleroderma; the estimates were lower than previous studies had suggested, and the confidence intervals relatively imprecise, making a definitive conclusion difficult. SUMMARY: There have been several papers published related to cancer in the rheumatic diseases, particularly inflammatory arthritis, Sjogren's syndrome, systemic lupus erythematosus, and scleroderma/systemic sclerosis. Continuing interest in the association between autoimmune rheumatic diseases and malignancy is likely, given the potential impact in terms of understanding both rheumatic diseases and cancer.

Autoimmune Diseases↗

Predictors of health status in women with fibromyalgia: a prospective study.

Although cross-sectional studies have identified correlates of dysfunction in fibromyalgia (FM) patients (e.g., psychological distress and pain), predictors of health status have not been previously investigated using a longitudinal research design. We gathered data from 156 women who met American College of Rheumatology criteria for primary FM recruited from both tertiary care and community settings. Stepwise multiple linear regression analysis indicated that poorer health status (p < .0001) and more comorbidity (p = .0089) at baseline were predictors of poorer health status 6 months later. After controlling for these covariates, psychological distress contributed significantly to the model (p = .01). There was a trend indicating that palliative coping styles (i.e., self-care, energy conservation) altered the impact of pain on 6-month health status (p = .06). These findings highlight the need for multidisciplinary interventions that target psychological distress, coping, and comorbidity in patients with FM.

Adult↗

Bayesian modelling of imperfect ascertainment methods in cancer studies.

Tumour registry linkage, chart review and patient self-report are all commonly used ascertainment methods in cancer epidemiology. These methods are used for estimating the incidence or prevalence of different cancer types in a population, and for investigating the effects of possible risk factors for cancer. Tumour registry linkage is often treated as a gold standard, but in fact none of these methods is error free, and failure to adjust for imperfect ascertainment can lead to biased estimates. This is true both if the goal of the study is to estimate the properties of each ascertainment type, or if it is to estimate cancer incidence or prevalence from one or more of these methods. Although rarely applied in the literature to date, when cancer is ascertained by three or more methods, standard latent class models can be used to estimate cancer incidence or prevalence while adjusting for the estimated imperfect sensitivities and specificities of each ascertainment method. These models, however, do not account for variations in these properties across different cancer sites. To address this problem, we extend latent class methodology to include a hierarchical component, which accommodates different ascertainment properties across cancer sites. We apply our model to a data set of 169 lupus patients with three ascertainment methods and eight cancer types. This allows us to estimate the properties of each ascertainment method without assuming any to be a gold standard, and to calculate a standardized incidence ratio for cancer for lupus patients compared to the general population. As our data set is small, we also illustrate the effects as more data become available. We show that our model produces parameter estimates that are substantially different from the currently most popular method of ascertainment, which uses tumour registry data alone.

Bayes Theorem↗

Determinants of sleep quality in women with systemic lupus erythematosus.

OBJECTIVE: To characterize sleep complaints in women with systemic lupus erythematosus (SLE) and to identify correlates of sleep quality. METHODS: Sleep quality in 100 women with SLE was assessed using the Pittsburgh Sleep Quality Index (PSQI). Participants completed standardized questionnaires assessing depressed mood, leisure time physical activity, functional disability, and pain severity. A clinical examination determined disease activity, cumulative damage, and whether patients fulfilled the American College of Rheumatology criteria for fibromyalgia. A series of hierarchical multiple regressions were computed. RESULTS: The mean +/- SD global PSQI score was 6.98 +/- 4.03, with moderate to severe sleep impairment reported by 56% of the sample. The first model testing the importance of demographic factors was not statistically significant. In the disease-related model, the use of prednisone and functional disability both contributed to poor sleep quality (P < 0.001). The addition of level of exercise participation to the demographic set significantly added to the model (P = 0.001). Depression significantly added to the demographic set, explaining 29% of the variance (P < 0.0001). When these variables, along with disease related variables, were simultaneously regressed on the PSQI Global Score, only depressed mood appeared as a significant independent determinant of global sleep quality (P < 0.001). However, the point estimates for the Beta coefficients were consistent with effects for lack of exercise and prednisone use. CONCLUSION: A significant proportion of women with SLE suffer from poor sleep quality. The findings suggest that depressed mood, prednisone use, and lack of exercise contribute to decreased overall sleep quality.

Disability Evaluation↗

Revisiting the issue of malignancy risk in systemic lupus erythematosus.

Certain cancers occur more frequently in systemic lupus erythematosus (SLE) as compared with the general population, as recent data substantiates. The risk appears to be most heightened for lymphoma. Several pathogenic mechanisms may explain these observations, although little is definitively known. One particular concern relates to whether cancer risk in SLE is increased by medication exposures. Cooperative efforts to evaluate this have been undertaken by the Systemic Lupus International Collaborating Clinics and the Canadian Network for Improved Outcomes in Systemic Lupus research groups. This and other works in progress will, it is hoped, considerably advance the knowledge regarding the association between autoimmune diseases and malignancy.

Comorbidity↗

Exploring the links between systemic lupus erythematosus and cancer.

For decades, concern has been mounting that individuals with systemic lupus erythematosus (SLE) have increased susceptibility to cancer. Recent data confirm that certain cancers, particularly hematologic, occur more frequently in SLE than in the general population. Numerous pathogenic mechanisms are possible, but hypotheses remain largely speculative. In particular, data are inadequate on how cancer risk in SLE may be related to medication exposures. To evaluate the impact of medication exposures on cancer risk in SLE, cooperative efforts of Systemic Lupus International Collaborating Clinics and Canadian Network for Improved Outcomes in Systemic Lupus are currently in progress. This should provide much-needed insight into the pathogenesis of the association between cancer and SLE.

Humans↗

A comparison of prospective and retrospective evaluations of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index for systemic lupus erythematosus.

OBJECTIVE: To evaluate the comparability of prospective and retrospective evaluations of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI). METHODS: Consecutive patients meeting ACR criteria for SLE were enrolled prospectively in our cohort. Prospective SLICC/ACR DI scores were collected on the 134 cohort members who were observed in the cohort between 1993-1999. The last available prospective SLICC/ACR DI scores were compared to scores that were retrospectively assigned (for the corresponding time point) from chart review by a research nurse blinded to the prospective values. Intra- and inter-observer agreement was assessed. Kappa coefficients with 95% confidence intervals (CI) were determined. RESULTS: The kappa correlation coefficient for agreement between prospective versus retrospective total damage scores was 0.68 (95% CI 0.54-0.81). Moderate to very good agreement was also observed with respect to the 12 individual organ systems itemized in this damage index. Substantial agreement was found between assessments done by different research nurses and for repeat assessments done by the same research nurse. CONCLUSION: These data suggest good agreement between prospective and retrospective evaluations of the SLICC/ACR DI scores.

Adult↗

Health services costs and their determinants in women with fibromyalgia.

OBJECTIVE: Patients with fibromyalgia (FM) use health services extensively. Knowledge about costs of FM is limited because of non-inclusiveness in assessing direct costs, because attempts to assess indirect costs are largely absent, and because determinants of costs have yet to be identified. We investigated the 6-month costs (direct and indirect) in women with primary FM, and we identified determinants of direct costs. METHODS: Subjects (n = 180 women) completed a health resource questionnaire as well as measures of pain, psychological distress, comorbidity, and disability. Unit costs for resources were obtained from government, hospital, laboratory, and professional association sources. Regression modeling for 6-month direct cost included age, disability, comorbidity, pain intensity, psychological distress, education, and work status. RESULTS: The average 6-month direct cost was $CDN 2298 (SD 2303). The largest components were medications ($CDN 758; SD 654), complementary and alternative medicine (CAM; $CDN 398; SD 776), and diagnostic tests ($CDN 356; SD 580). Our most conservative estimate of average 6-month indirect cost was $CDN 5035 (SD 7439). Comorbidity and FM disability were statistically significant contributors to direct costs in the multivariate analysis. Costs increased by approximately 20% with each additional comorbid condition. CONCLUSION: Women with FM are high consumers of both conventional and CAM services. Our estimates of costs exceed those from most other studies; this may be due to our inclusion of a broader set of health services, medications, and indirect costs. Although in univariate analyses the number of comorbidities and indices of the effect of FM, psychological distress, and pain intensity were associated with higher direct cost, in a multiple regression analysis, only the measure of FM disability and the number of comorbidities were significant direct-cost determinants. FM also imposes important indirect costs, which were nearly 70% of the economic burden.

Adult↗

Patient-physician discordance in fibromyalgia.

OBJECTIVE: Discordance between patients' and physicians' health perceptions and satisfaction with the office visit in fibromyalgia (FM) has not been examined. We investigated this phenomenon to identify demographic, clinical, and psychosocial factors associated with patient-physician discordance on physical functioning, well being, and satisfaction with the office visit. METHODS: A sample of 182 women were examined by a rheumatologist to confirm the FM diagnosis. Patients and physicians independently completed the Patient-Physician Discordance Scale to assess perceptions of health and satisfaction with the office visit. Patients also completed questionnaires pertaining to sociodemographics, social support, disability, perceived stress, and psychological distress following the office visit. Separate generalized estimating equations with forward selection, controlling for the possible dependence of outcomes among patients of same physician, were modeled for each measure of discordance. RESULTS: The highest discordance score was on satisfaction with the office visit; physicians systematically underestimated patients' level of satisfaction. Higher levels of satisfaction with social support (p < 0.02) and more psychological distress (p < 0.03) were marginally associated with greater discordance on physical functioning. Higher levels of satisfaction with social support (p < 0.003), younger age (p < 0.02), and lower disability (p < 0.03) were associated with greater discordance on well being. More sexual abuse (p < 0.01) was significantly associated with more discordance on satisfaction with the office visit. CONCLUSION: There is a gap between what patients with FM and rheumatologists examining them experience during the office visit. Psychosocial factors contribute to our understanding of discordance on physical functioning, well being, and satisfaction.

Activities of Daily Living↗

Do traditional Gail model risk factors account for increased breast cancer in women with lupus?

OBJECTIVE: To determine to what extent the observed experience of breast cancer in a combined cohort of patients with systemic lupus erythematosus (SLE) could be explained by the profile of breast cancer risk factors. METHODS: Data were pooled from 2 centers, the Montreal General Hospital and the Feinberg School of Medicine at Northwestern University in Chicago. For each female cohort member, the probability of developing breast cancer during followup was estimated based on factors (including the individual's age, parity, age at first live birth, age of menarche, personal history of benign breast disease, and family history) using the Gail model, an established model for predicting breast cancer risk. The actual occurrence of cancer cases was determined by linkage with regional cancer registries. RESULTS: Of the 583 women in the combined cohort, 5 had been diagnosed with breast cancer prior to cohort entry, and 14 declined participation. In those remaining, 12 cases of breast cancer occurred compared to 5.6 predicted by the Gail model (standardized incidence ratio 2.1, 95% confidence interval: 1.1, 3.7). Thus, after controlling for risk factors, the incidence of breast cancer was elevated. CONCLUSION: Our data suggest that the risk of breast cancer in our SLE cohort is not completely explained by traditional factors found in the Gail model. Other factors, such as carcinogenic exposures (i.e., alkylating agents and immunosuppressive drugs) or the immunologic dysregulation of SLE itself, may be contributory.

Age Factors↗

Adherence to ophthalmologic monitoring for antimalarial toxicity in a lupus cohort.

OBJECTIVE: Antimalarial agents (hydroxychloroquine and chloroquine) are important in the treatment of various rheumatic diseases, including systemic lupus erythematosus (SLE). Although these agents may lead to ocular complications, little is known about adherence to policies for ophthalmologic monitoring. We investigated adherence to the 1996 American College of Rheumatology (ACR) guidelines (recommending yearly ophthalmologic assessments) at our clinic, and determined the factors associated with nonadherence. METHODS: Chart review of the Montreal General Hospital lupus clinic cohort. RESULTS: Of 195 subjects with at least one full year of antimalarial exposure during 1996-2001, 5 refused participation and data on ophthalmology monitoring was incomplete for 42. Of the remaining 148 patients, 47 (32%) had missed at least one annual ophthalmology assessment (were nonadherent) during the interval; almost half of these had missed </= 2 assessments. Nonadherence was present in 50% of the 52 patients who had been taking an antimalarial agent for </= 5 years. In adjusted logistic regression models, cumulative damage (measured by the Systemic Lupus International Collaborating Clinics/ACR Damage Index) and antimalarial exposure </= 5 years were predictive of nonadherence. Adjusted estimates indicated a 1.2-fold increase (95% CI 1.0, 1.5) in the odds of nonadherence for every point increase in the total Damage Index score. The adjusted OR for individuals exposed to an antimalarial for </= 5 years was 5.2 (95% CI 2.1, 13.8). CONCLUSION: Our results indicate incomplete adherence to ACR guidelines at our center. Because patients with higher Damage Index scores were more likely to have missed ophthalmology appointments, even after adjusting for pertinent covariates, it suggests that sicker patients may be more at risk of nonadherence. The association of nonadherence with duration of antimalarial exposure, while not surprising, is still an important reminder that adherence to ophthalmologic monitoring may decrease as risk for retinal toxicity is increasing.

Adult↗