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M B Urowitz

Publications and source records attributed to M B Urowitz.

At least 55 records · Page 3Linked to original sources
PubMed1998

Efficacy and tolerability of methotrexate in antimalarial resistant lupus arthritis.

OBJECTIVE: To determine the efficacy and tolerability of low dose intermittent methotrexate (MTX) in antimalarial resistant lupus arthritis. METHODS: Retrospective cohort study from the University of Toronto Lupus Clinic. Seventeen patients receiving MTX for persistently active arthritis, despite a previous therapeutic trial of antimalarial therapy, were identified. Seventeen control patients were selected who had active arthritis despite 6 months of treatment with an antimalarial agent. The primary outcome measure was a reduction in actively inflamed joint count of at least 60% over 6 months. Secondary outcome measures were the reduction in steroid dose and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and tolerability of MTX. RESULTS: Baseline characteristics including sex, race, age at diagnosis, and concomitant use of other medications were similar. Patients in the MTX group had a higher mean joint count than the control group at baseline (p = 0.003). After 6 months, 15/17 patients in the MTX group showed at least a 60% improvement in the joint count compared to only 2/17 for the control group (p < 0.001). The mean daily prednisone dose fell by 35 and 27% in the MTX and control groups, respectively (p = NS). A mean SLEDAI reduction of 0.76 was obtained in the MTX group, compared to an increase of 2.05 in the control group (p = 0.03). Over a mean followup period of 3.5 years, toxicity leading to termination was infrequent, as only 2 patients discontinued MTX due to a side effect. CONCLUSION: Methotrexate appears to be effective in the treatment of antimalarial resistant lupus arthritis and is well tolerated.

Adult↗
PubMed1998

Fatigue in lupus is not correlated with disease activity.

OBJECTIVE: The relationship between fatigue and disease activity in systemic lupus erythematosus (SLE) has been questioned. We examined whether self-reported fatigue in patients with SLE is correlated with disease activity. METHODS: Consecutive patients with SLE at the University of Toronto Lupus Clinic were evaluated for disease activity using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). They were also evaluated for fibromyalgia (FM) by American College of Rheumatology criteria. One hundred patients completed the following health status questionnaires: the Fatigue Severity Score (FSS), Center for Epidemiologic Studies Depression Scale (CES-D), and Medical Outcomes Study Short Form Health Survey (SF-20). Disease activity was measured by the SLEDAI. Statistical correlations were made using the Spearman test. RESULTS: No significant correlation was found between FSS scores and SLEDAI (p = NS). Fatigue was found to be highly correlated with the presence of FM (p < 0.05) and depression (p < 0.01). In addition, fatigue was significantly associated with lower performance in all 6 domains of the SF-20 (p < 0.001); disease activity correlated with decreases in social function, mental health, and health perception areas of the SF-20. SLEDAI was not found to correlate with FM (p = NS). CONCLUSION: Fatigue in patients with SLE does not correlate with disease activity. However, fatigue is correlated with FM, depression, and lower overall health status in this population. Fatigue is a manifestation of these conditions, which are commonly co-expressed in SLE, and may reflect a decreased overall coping ability in these patients, rather than active disease itself.

Adult↗
PubMed1998

Radiographic reports in osteonecrosis of the hip in systemic lupus erythematosus.

The purpose of this study was to assess the reliability and accuracy of the modified Marcus and Enneking classification of osteonecrosis of the femoral head in patients with systemic lupus erythematosus when applied to the reading of the original radiographs and then applied to interpreting the radiologist's written report. Thirty anteroposterior radiographs of the hip from patients with systemic lupus erythematosus with varying degrees of osteonecrosis were selected and submitted to a panel of two rheumatologists and an orthopaedic surgeon who individually graded the radiographs using the modified Marcus and Enneking method. Agreement was determined by the kappa statistics. Identical staging was assigned in 21 of the 30 radiographs by all three observers, providing a weighted kappa of 0.88. Identical staging was assigned by all three observers in 26 of the 30 reports, giving a kappa of 0.95. There was agreement in the staging of 23 of the 30 radiographs by actual reading and the radiologist's report, with a weighted kappa of 0.86. Discordant gradings resulted primarily because the Marcus and Enneking method does not account for degenerative changes on the femoral side of the hip joint. The authors conclude that the radiologist's report can be used to stage osteonecrosis when interpreted by expert observers and when those reports contain all critical information required for staging. The authors recommend that the Marcus and Enneking classification be modified to include changes on the femoral side of the joint.

Femur Head Necrosis↗
PubMed1998

Clinical predictors of fetal outcome in systemic lupus erythematosus.

OBJECTIVE: To describe the fetal outcomes in systemic lupus erythematosus (SLE) in the University of Toronto Lupus Clinic Cohort and to identify clinical or serological factors that would predict pregnancy loss and poor fetal outcome. METHODS: Seventy-three patients with 141 pregnancies were identified between 1970 and 1995. Patients were evaluated before pregnancy and at each trimester with a standardized protocol. Analysis included descriptive statistics and univariate and multivariate analysis. RESULTS: There were 86 (60.1%) live births, 34 (23.8%) spontaneous abortions, 3 (2.2%) stillbirths, and 20 (14%) therapeutic abortions. Of live births, 21 (24.4%) were premature babies, 6 (7.9%) intrauterine growth retardation, 3 (3.5%) had neonatal lupus, 2 (2.3%) congenital malformations, and there were 2 (2.3%) perinatal deaths. Maternal renal disease was the only statistically significant predictor for fetal loss (p<0.0 12) and hypertension for poor fetal outcome (p<0.024) using univariate analysis. CONCLUSION: Most lupus pregnancies do well, but there is an increased incidence of adverse fetal outcome. Predictive factors for adverse fetal outcome include maternal renal disease and hypertension.

Adult↗
PubMed1998

Smoking interferes with efficacy of antimalarial therapy in cutaneous lupus.

OBJECTIVE: There have been occasional reports of patients with refractory cutaneous lupus improving after cessation of cigarette smoking. It has been hypothesized that the effects of cigarette smoking on hepatic cytochrome P450 induction can alter the metabolism of antimalarials. Our objective was to determine the role of smoking in the efficacy of antimalarial therapy in cutaneous lupus. METHODS: A retrospective cohort study from the University of Toronto Lupus Clinic. Patients with either acute discoid or subacute cutaneous lupus (SACL) who received antimalarial therapy for their cutaneous lesions were selected. The smoking group consisted of regular smokers, while the nonsmoking group consisted of individuals who never smoked during the study period. The primary outcome measure was the complete resolution of the cutaneous lesion at 6 and 12 months of antimalarial therapy. Secondary outcome measures included the mean steroid dose and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score. Analysis included descriptive statistics and Fisher's exact test. RESULTS: Seventeen smokers (9 with discoid lupus, 5 SACL, 3 both) and 19 nonsmokers (11 discoid, 6 SACL, 2 both) were identified. The cutaneous eruption resolved completely in 3/17 smokers versus 9/17 nonsmokers after 6 months of antimalarial therapy (p < 0.035) and 3/16 smokers and 9/17 nonsmokers at 12 months (p < 0.046). There was no significant change in the mean steroid dose or SLEDAI in either group. CONCLUSION: Smoking appears to decrease the efficacy of antimalarial therapy in cutaneous lupus. The interaction between smoking and the efficacy of antimalarials in a variety of SLE presentations should be investigated further.

Adult↗
PubMed1997

The reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index in patients with systemic lupus erythematosus.

OBJECTIVE: To test the reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) in the assessment of patients with SLE. METHODS: Ten patients with SLE, representing a spectrum of damage and activity, were included. Each patient was examined by 6 of 10 physicians from 5 countries, representing 10 lupus clinics. The SLICC/ACR Damage Index was used to assess accumulated damage, and the SLEDAI was used to assess disease activity. The order of the patients and physicians was randomized according to a Youden square design. RESULTS: The SLICC/ACR Damage Index detected differences among patients (P < 0.001). There was no detectable observer difference (P = 0.933), and there was no order effect (P = 0.261). Similar results were obtained with the SLEDAI. There was concordance in the SLICC/ACR Damage Index among observers, despite a wide spectrum of disease activity detected by the SLEDAI. CONCLUSION: Physicians from different centers are able to assess patients with SLE in a reproducible way, using the SLEDAI to assess disease activity and the SLICC/ACR Damage Index to assess accumulated damage.

Adult↗
PubMed1997

Cytotoxic therapy in systemic lupus erythematosus. Experience from a single center.

The present survey of cytotoxic therapy from a single large lupus clinic has shown that approximately 33% of the patients have received cytotoxic therapy at some point in their course. These agents were initiated for a variety of manifestations, with renal manifestations being the major indication, accounting for 28.2% of the cytotoxic agents used. Other common indications for initiation of cytotoxic therapy included steroid sparing (18.4%), global flare (12.5%), neurologic manifestations (11.4%), and musculoskeletal (8.6%). Azathioprine, methotrexate, and cyclophosphamide accounted for 98% of all cytotoxic agents used. Azathioprine was the most frequently used cytotoxic drug (70%), followed by methotrexate (21.5%) and cyclophosphamide (9.4%). Cytotoxic agents were used sequentially in 12.5% of patients and in combination in 4.2% of the patients. Overall, the use of cytotoxic therapy appears to be beneficial in reducing global disease activity, as the mean SLEDAI fell by 2.59 (33%) over 6 months of cytotoxic therapy, and the mean steroid dose was reduced by 37% over the same time period. There was also an improvement in most organ-specific indications with the use of cytotoxic agents. Overall the cytotoxic agents were well tolerated, with 17% of the courses being discontinued due to a side effect. Cytopenia was the most common side effect necessitating discontinuation of cytotoxic agents.

Adolescent↗
PubMed1997

Mortality studies in systemic lupus erythematosus. Results from a single center. III. Improved survival over 24 years.

OBJECTIVE: Prognosis studies have indicated that survival of patients with systemic lupus erythematosus (SLE) has improved significantly. We investigate whether the apparent improvement in the survival of patients with SLE is associated with a reduction in the risk of death compared with the general population, or with changes over time in the distribution of various prognostic factors. METHODS: The University of Toronto cohort of 720 patients with SLE followed between 1970 and 1994 was divided into 3 groups based on year of entry into study: Group A 1970-77, Group B 1978-85, Group C 1986-1994. Standardized mortality ratios (SMR) were calculated for each cohort. Prognostic factors for death occurring in the first 8 yr period after entry into the study were examined in each of the 3 cohorts. Analysis involved chi-squared tests for categorical values and unpaired t tests for continuous variables. RESULTS: Group A comprised 183 patients, Group B 332 patients, and Group C 205 patients. An examination of the first 8 years of evaluation for each group revealed that the SMR decrease over time ranged from 10.1-fold greater than the general population in Group A, to 4.8-fold in Group B, to 3.3-fold in Group C. Prognostic factors for death varied over time, with vasculitis decreasing and hyperlipidemia increasing. CONCLUSION: Survival in SLE has improved over 24 yrs in the University of Toronto cohort more than the health of the general population has improved. This improved survival was not related to changing demographics, severity of lupus at presentation, major change in disease patterns, or new modalities of treatment.

Adolescent↗
PubMed1997

Pattern of neuropsychologic dysfunction in inactive systemic lupus erythematosus.

The pattern of neuropsychological dysfunction in patients with inactive systemic lupus erythematosus (SLE) was examined. Fifty-eight subjects with inactive SLE and 47 healthy controls were administered a standardized neuropsychological test battery. Summary scores reflecting 18 different cognitive processes were derived. Subjects were designated cognitively impaired if three or more summary scores differed significantly from premorbid estimates of cognitive functioning. Cognitive impairment was identified in 43% of subjects with inactive SLE and 19% of healthy controls. Subjects with inactive SLE, as a group, performed significantly worse than healthy controls on measures of auditory verbal memory, visual spatial memory, psychomotor speed, and motor functioning. A significantly greater proportion of subjects with inactive SLE than healthy controls was impaired only on a measure of visual spatial memory. Cognitive impairment in subjects with inactive SLE was associated with increasing age. There were no associations between cognitive impairment and current depressive symptoms or current corticosteroid use. These findings suggest that cognitive dysfunction occurs frequently in inactive SLE. The variability of performance of subjects with inactive SLE is consistent with the heterogeneity of CNS involvement in the disease.

Adult↗
PubMed1997

Fibromyalgia is a major contributor to quality of life in lupus.

UNLABELLED: OBJECTIVE; To determine whether individual variables of the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and Systemic Lupus International Coordinating Committee/American College of Rheumatology (SLICC/ACR) Damage Index were associated with any of the domains of the Short Form 36 (SF-36) quality of life measure, and to assess the contribution of fibromyalgia (FM) to the quality of life measure. METHODS: Patients with systemic lupus erythematosus (SLE) seen between December 1994 and May 1995 completed SF-36 questionnaires at the time of their clinical evaluations at the Lupus Clinic. Disease activity was measured by SLEDAI, damage was assessed by the SLICC/ACR Damage Index, and FM was diagnosed in the presence of widespread pain and > or = 11 of 18 FM tender points. The components of SLEDAI and the Damage Index were compared to the domains of the SF-36 using Pearson correlation coefficients. A t test was used to compare the variables in patients with and without FM. RESULTS: One hundred nineteen patients with SLE participated in the study. Presence of FM, which occurred in 21% of the patients, was not related to either the overall scores or any of the components of SLEDAI or Damage Index, but was highly correlated with all 8 domains of the SF-36. The correlations ranged from -0.26 to -0.43, with associated p values of 0.007 to 0.0001. CONCLUSION: In a cross sectional study of patients with SLE at one point in time the SF-36 reflected the presence of FM rather than disease activity or damage.

Adult↗
PubMed1997

Hormone replacement therapy in systemic lupus erythematosus.

OBJECTIVE: To test whether hormone replacement therapy (HRT) causes an increase in lupus flares. METHODS: Sixteen postmenopausal patients with systemic lupus erythematosus (SLE) who had been taking HRT for at least 12 months were included in the study. Thirty-two controls were matched to patients for age at start of hormone therapy and calendar year of followup. The incidence of disease flare was defined as any increase in Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) over 12 months from baseline in these 2 groups; incidence of flare was compared by McNemar's test or Mantel-Haenszel test. RESULTS: Control patients were older at diagnosis (38.8 vs 30.5 yrs) and at presentation to clinic (41 vs 30 yrs). HRT patients had longer disease duration (17.9 vs 5.6 yrs). SLEDAI at presentation was similar in both groups. There was no statistically significant difference in the rates of flares in both groups. CONCLUSION: The use of HRT in postmenopausal women with SLE does not appear to increase the rate of lupus flares over a one year followup.

Acute Disease↗
PubMed1996

Malignancy in systemic lupus erythematosus.

OBJECTIVE: To estimate the risk of cancer in patients with systemic lupus erythematosus (SLE). METHODS: Patients with SLE (n = 724) have been followed prospectively, for 24 years, at the University of Toronto Lupus Clinic. The diagnosis of cancer was confirmed by histologic or autopsy reports. Standardized rates of cancer and standardized incidence rates (SIR) (ratio of observed-to-expected cancers) were used to estimate the risk for cancers. RESULTS: Twenty-four cancers were identified in 23 SLE patients (3.2%) during 7,233 patient-years of followup. Compared with the Ontario population, the overall estimated risk for all cancers was not increased in the lupus cohort (SIR 1.08, 95% confidence interval 0.70-1.62). A 4.1-fold increased risk for hematologic cancers was observed, due mainly to an increased risk of non-Hodgkin's lymphoma. The risk for cancer was significantly lower in the SLE cohort compared with patients with rheumatoid arthritis (RA) and systemic sclerosis (SSc). CONCLUSION: SLE is associated with a lower risk of all cancers compared with RA and SSc, but an increased risk for non-Hodgkin's lymphoma compared with the general population.

Adolescent↗
PubMed1996

The significance of anticardiolipin antibodies in patients with lupus nephritis.

The objective of this study was to determine whether anticardiolipin antibodies (ACL) in SLE patients are associated with a specific pattern of lupus nephritis and/or with renal microvascular changes. Patients with SLE, followed prospectively between June 1991-May 1994 at The Wellesley Hospital Lupus Clinic, who underwent a renal biopsy were included. The ACL was measured by the ELISA according to international standardized method. Renal biopsy morphology was assessed using the WHO criteria for the classification of lupus nephritis. Renal vascular changes included glomerular hyaline thrombi, intimal fibrosis and intraluminal thrombi of renal arterioles. There were 23 SLE patients. The mean age at diagnosis of SLE was 28.2 years and the mean disease duration was 6.3 years. Of these 10 (43%) had high levels of ACL. No difference in the frequency of severe nephritis (Class III and IV) was identified amongst patients with and without ACL. Mesangial nephritis was more common in patients with ACL 40% vs 0, p = 0.02). Glomerular hyaline thrombi occurred in 3 (13%) patients. None of them had positive ACL. Renal vascular lesions included intimal proliferation in 4 (ACL + , 1) occluded lumens by thrombi in 2 (ACL + 1). Our data indicate that the development of glomerular and/or microvascular changes is not related to the presence of ACL.

Adolescent↗
PubMed1996

A comparison of five health status instruments in patients with systemic lupus erythematosus (SLE).

The aim of the present investigation was to assess and compare health status instruments in SLE. One hundred and twenty-five patients completed five health status instruments: the Health Assessment Questionnaire (HAQ), Functional Ability Index, the Fatigue Severity Scale (FSS), the Disability Days Measure (DDM), the Centre for Epidemiological Studies-Depression Scale (CES-D), and the Medical Outcomes Study (MOS) Short Form Health Survey during their Clinic visit. Disease activity was measured using the SLE Disease Activity Index (SLEDAI). All instruments described a spectrum of quality of life outcomes in these patients. An inter-instrument correlation analysis revealed that components of the MOS correlated significantly with each of the other instruments used. There was no correlation between any of the instruments used and the SLEDAI. We conclude that health status assessment as measured by the MOS short form is a valid independent outcome measure in patients with SLE.

Adolescent↗
PubMed1995

CAMPATH-1H, a humanized monoclonal antibody, in refractory rheumatoid arthritis. An intravenous dose-escalation study.

OBJECTIVE: To evaluate the biologic response, tolerability, and potential clinical effect of a humanized antilymphocyte monoclonal antibody, CAMPATH-1H, in patients with rheumatoid arthritis (RA). METHODS: Forty adult patients with active, refractory RA were treated with CAMPATH-1H, given intravenously, in a multicenter, open, single-dose-escalation study. Patients were assigned to dose groups of 1, 3, 10, 30, 60, and 100 mg CAMPATH-1H. RESULTS: There was a profound, immediate, and sustained reduction of the peripheral lymphocyte count; the most susceptible were the levels of CD4+ and CD8+ cells, which remained depressed during the study period. Sixty-three percent of patients developed antibodies to CAMPATH-1H. Side effects occurred frequently throughout the first 24 hours following infusion, and included fever, headache, nausea, vomiting, and hypotension. All of the immediate drug toxicities resolved within the initial 24-hour postdosing period. One patient developed a reactivation of Mycobacterium xenopi infection 10 weeks following infusion. Sixty-five percent of patients developed a clinical response; the mean duration of response was 2 weeks. CONCLUSION: CAMPATH-1H is a lymphocyte-depleting antibody that is biologically potent even after single-dose therapy. There was no correlation between biologic effect and clinical response. Sustained lymphocyte suppression was observed. Acute infusion toxicities were observed in most patients. The role of depleting monoclonal antibodies in the treatment of RA should be reevaluated.

Adult↗
PubMed1995

Anticardiolipin antibodies in systemic lupus erythematosus: clinical and laboratory correlations.

PURPOSE: To examine the link between anticardiolipin antibodies and the features of antiphospholipid syndrome in patients with systemic lupus erythematosus (SLE). PATIENTS AND METHODS: In this prospective cohort study conducted in a single center, 390 SLE patients were followed up between June 1991 and 1994. At each assessment, a complete history, physical examination, and laboratory evaluation (including measurement of anticardiolipin antibodies) were performed according to a standard protocol. RESULTS: Forty-seven percent of the patients had an elevated level of anticardiolipin antibodies. In the univariate analysis, elevated anticardiolipin antibody levels were found to correlate with thrombocytopenia (P = 0.006), prolonged activated partial thromboplastin time (aPTT) (P = 0.003), and positive direct and indirect Coombs' test result's (P < 0.001). No correlation was identified with any of the clinical features of antiphospholipid syndrome. In the multivariate analysis, anticardiolipin antibodies remained highly associated with thrombocytopenia (odds ratio [OR] 4.05, P = 0.02), positive direct Coombs' test (OR 2.31, P < 0.001), and prolonged aPTT (OR 1.73, P = 0.03). In the multivariate model using venous/arterial thrombosis as the outcome variable, only prolonged aPTT was associated with venous/arterial thrombosis (OR 7.9, P < 0.001). None of the laboratory variables were found to correlate with fetal loss. CONCLUSIONS: The presence of anticardiolipin antibodies in patients with SLE is associated with prolonged aPTT, thrombocytopenia, and positive Coombs' test result, but not with antiphospholipid syndrome. Prolonged aPTT is strongly associated with venous/arterial thrombosis.

Adolescent↗
PubMed1995

The use of single photon emission computerized tomography in neuropsychiatric SLE: a pilot study.

OBJECTIVE: To test the sensitivity of single photon emission computerized tomography (SPECT) in detecting brain abnormalities in cases of definite active neuropsychiatric systemic lupus erythematosus (NPSLE) in a blinded, prospective pilot study. METHODS: Fourteen patients fulfilling at least 4 of the American College of Rheumatology criteria for the classification of SLE plus positive serology manifested by either elevated DNA binding or decreased serum complement and a recent neuropsychiatric event were evaluated with cerebral SPECT using hexa-methyl-propylene-amine-oxime labeled 99Tc. Secondary causes such as infection, uremia, hypertension, drugs, and metabolic abnormalities were excluded. Patients underwent brain scan and electroencephalogram (EEG) for comparison. When clinically indicated, CT scan, magnetic resonance imaging, angiography, and lumbar puncture were performed. RESULTS: SPECT scan abnormalities were noted in 12/14 patients and brain scan was abnormal in 12/14 patients. SPECT and brain scan were in accordance in 12/14 patients (11 patients both positive and 1 both negative) and the combination of SPECT and brain scan yielded 13/14 positive results. In the 3 patients with headache, SPECT scan was negative in 2/3, despite positive EEG and one with a positive brain scan. The positive SPECT in the patient with headache showed an old cerebrovascular accident (CVA), which was confirmed by CT scan. The most consistent CT finding was cortical atrophy; however, SPECT identified a lesion in the occipital cortex in a patient with seizure, and a lesion in the basal ganglia in a patient with ataxia. CONCLUSION: In clinically and serologically active NPSLE, SPECT is a sensitive diagnostic tool. When further stratifying NPSLE into focal (seizure, ataxia, CVA) and diffuse (headache, organic brain syndrome, psychosis), SPECT appeared to be sensitive for focal disease and for most diffuse manifestations, with the exception of headache. The high sensitivity of SPECT in patients with true, positive NPSLE merits further controlled studies in unselected patients with SLE.

Adult↗