Cindy Flower

Systemic lupus erythematosus in an African Caribbean population: Incidence, clinical manifestations, and survival in the Barbados National Lupus Registry

To assess the epidemiology, clinical features, and outcomes of systemic lupus erythematosus (SLE) in the predominantly African Caribbean population of Barbados.

High-risk variants of cutaneous squamous cell carcinoma in patients with discoid lupus erythematosus: a case series.

Cutaneous squamous cell carcinoma, the second most common form of non-melanotic skin cancer, may develop in long-standing discoid lesions, especially those that are depigmented and located in sun-exposed areas. The clinical course of this complication may be aggressive, with early metastases and a risk of mortality. We report three cases demonstrating this emerging trend of secondary squamous cell carcinoma in discoid lesions as the incidence of this secondary malignancy in other diseased skin lesions is on the decline.

Comparison of the Systemic Lupus Erythematosus Activity Questionnaire and the Systemic Lupus Erythematosus Disease Activity Index in a Black Barbadian Population

In Barbados, use of the Systemic Lupus Erythematosus (SLE) Disease Activity Index (SLEDAI) is limited by the unavailability of serologic markers. The SLE Activity Questionnaire (SLAQ) excludes laboratory measurements and is therefore more accessible. Here, we investigate the agreement between the SLAQ, the SLEDAI, and the physician global assessment (PGA). A pilot of 32 participants completed the SLAQ and SLEDAI. The tools were compared (1) in their original format, (2) limited to common indices, and (3) limited to the same patient recall period. We compared the proportions of persons reporting disease activity and the concordance between calculated activity scores for SLAQ versus SLEDAI and for SLAQ versus PGA. Seventy-eight percent versus 59% of participants reported disease activity with the original SLEDAI versus SLAQ, respectively. The relationship was reversed to 22% versus 59% when the matched item tools were compared. Concordance was 0.62 (95% CI 0.42–0.81) between the original scores, 0.70 (0.57–0.83) when restricted by matched items, and 0.72 (0.59–0.84) when further restricted by recall period. Concordance between the SLAQ and PGA was 0.56 (0.32–0.80). Reversal of the disease activity percentage in the matched items comparison highlights the inadequacy of tools that exclude laboratory measurements and suggests that the subjective nature of SLAQ may contribute to over-reporting. Further work is needed to produce a robust disease activity tool apt for resource-constrained environments.

The Effect of Psychosocial and Neuropsychiatric Factors on Medication Adherence in a Cohort of Women With Systemic Lupus Erythematosus.

BackgroundMedication adherence in systemic lupus erythematosus (SLE) reduces disease activity and the risk of flares. ObjectivesWe evaluated adherence in women with SLE who exhibit high morbidity and mortality. We evaluated demographic data and 2 conventional adherence predictors: self-efficacy and health literacy, along with 2 potential neuropsychiatric SLE complications: cognitive dysfunction and depression. MethodsOne hundred six women randomly selected from the Barbados National Lupus Registry completed the Self-efficacy for Appropriate Medication Use Scale, Rapid Estimate of Adult Literacy in Medicine–Short Form, Cognitive Symptom Inventory, Beck Depression Inventory II, and Morisky’s Medication Adherence Questionnaire (MAQ). This study explored the effects of psychosocial and neuropsychiatric functioning on adherence using ordinal logistic regression. ResultsSixty percent reported high MAQ scores. The probability of high MAQ scores was lower among younger patients (P = 0.001) and those with shorter disease duration (P = 0.05). The probability of high MAQ scores fell with lower perceived self-efficacy (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.73–0.89; P < 0.001), worsening cognitive function (OR, 0.90; 95% CI, 0.84–0.97; P = 0.004), and increasing depression (OR, 0.93; 95% CI, 0.88–0.97; P = 0.002). There was no strong relationship between MAQ score and health literacy (OR, 0.37; 95% CI, 0.13–1.03; P = 0.06). ConclusionWomen with SLE who are younger and those with shorter disease duration should be assessed for medication adherence. Screening at diagnosis followed by routine assessment of cognitive dysfunction and depression along with perceived self-efficacy may further identify the most vulnerable subgroup who should be targeted with personalized intervention strategies.

Report of an international symposium on narrowing the Gap in the treatment and study of SLE worldwide: minimum best practices in the management and monitoring of moderate to severe SLE and improving outcomes in constrained environments

Disparities in health outcomes occur in systemic lupus erythematosus (SLE) especially in economically disadvantaged populations. At the 9th International Congress on SLE, June 24–27, 2010, held in Vancouver, British Columbia, a symposium “Narrowing the Gap in the Treatment and Study of SLE worldwide” was held. Participating physicians from the Caribbean, Central and South America, Asia, Portugal, Africa and impoverished areas of the United States detailed their constraints and desires. These were remarkably consistent. Out of these discussions, a statement on minimum best practice was put forth aimed at the cost-effective management of SLE focusing on the critical factors that make a difference and are feasible even in the most challenging environments. Approaches to designing studies and establishing research and mentoring collaborations was also discussed. The ultimate aim was to provide an avenue for the improvement of care and outcomes for patients with SLE worldwide.

Extensive extranodal adult T-cell lymphoma presenting with a lytic arthropathy of the ankle.

A case is presented of a 44-year-old human T-cell lymphotropic virus-1 seropositive Afro-Caribbean man whose adult T-cell lymphoma presented with an ankle arthropathy. Over a period of weeks he developed subcutaneous tumor masses, osteolytic lesions, sinonasal involvement, and spinal disease culminating in death 4 months after his diagnosis. The case highlights the extranodal manifestations, generally, and rheumatological complications, specifically, of this very aggressive form of lymphoma with review of the relevant literature. Consideration should be given to the possibility of this condition in individuals originating from known endemic areas, notably, the Caribbean, southwestern Japan, South and Central America, parts of southeastern United States, and equatorial Africa.

The spectrum of neuropsychiatric lupus in a Black Caribbean population: a report of the Barbados National Lupus Registry:

Objective The objective of this study was to examine neuropsychiatric lupus in a Black Caribbean population. Methods We reviewed Barbados National Lupus Registry patients with ≥4 American College of Rheumatology criteria and a diagnosis of neuropsychiatric lupus using the American College of Rheumatology 19 case definitions. Results From 366 patients with four or more American College of Rheumatology criteria for systemic lupus erythematosus, 55 (15%) had evidence of neuropsychiatric lupus. There were 51 females and four males (F:M = 13:1) with a median age of 31 years. A total of 76.4% had a single neuropsychiatric lupus complication and 23.6% had two or three complications occurring sequentially or concurrently. The top three complications were psychosis – 49.1% (95% CI 35.8, 62.5); ischaemic stroke – 32.7% (21.4, 46.5); and generalized tonic-clonic seizures – 12.7% (6.0, 24.8). Twelve of the American College of Rheumatology 19 neuropsychiatric syndromes were represented: 91.2% central; 8.8% peripheral. There were 521 observation years, and for 32 patients (58%) neuropsychiatric lupus was a presenting feature. For the remaining 23 (42%) the first neuropsychiatric lupus event came after systemic lupus erythematosus diagnosis – median time of two years. Of the 22 deaths, systemic lupus erythematosus nephritis caused almost half (45.5%) at a median age of 32. The prevalence of nephritis was lower in the neuropsychiatric lupus subgroup (25.5%) compared with the Barbados National Lupus Registry data (47%) (P = 0.01). Ischaemic stroke caused 22.7% of deaths at a median age of 46 and was the main cause of chronic neurologic deficits amongst survivors. Conclusion Neuropsychiatric lupus was an early cause of morbidity in systemic lupus erythematosus with predominantly singular central nervous system complications, the most common of which was psychosis. Most deaths occurred at a young age, principally from systemic lupus erythematosus nephritis. Ischaemic stroke was the main neurologic cause of death and disability.

Lacy reticular-pattern calcinosis in adult dermatomyositis.

Dermatomyositis (DM) is an autoimmune connective tissue disease associated with calcinosis, uncommon in adults. A 61-year-old African Caribbean woman with a 6-year history of DM presented with a 1-year history of thickening of the skin and subcutaneous tissue of the …