Impact of COVID-19 pandemic on rheumatoid arthritis from a Multi-Centre patient-reported questionnaire survey: influence of gender, rural-urban gap and north-south gradient

Impact of COVID-19 Pandemic on Patients With Rheumatic Diseases in Medina, Saudi Arabia: An Observational Cross-Sectional Study

INTRODUCTION

The Coronavirus disease of 2019 (COVID-19) pandemic undoubtedly ranks among the most health-impacting pandemics throughout medical history. Although the COVID-19 global public health emergency has ended, lessons need to be learned to be more ready to face similar pandemics in the future. Few studies in Saudi Arabia discuss the impact of the COVID-19 pandemic on autoimmune rheumatic disease (AIRD) patients. Thus, this study was conducted to elaborate on the effects of the COVID-19 pandemic on AIRD patients and rheumatology practices in Saudi Arabia.  Methods: This observational cross-sectional study was conducted among patients aged over 14 with AIRD using a pre-designed validated survey questionnaire. Data were collected from AIRD patients who were following up between November 2021 to April 2022 at the Rheumatology Clinic of King Fahad General Hospital in Madinah City, Saudi Arabia. This center was chosen as being the main hospital in the city following patients of AIRD.

RESULTS

A total of 324 patients were included in our study, with the majority (n=264, 81.5%) being females. The mean age was 44.42±14.4 years. Clinical data revealed that 115 (35.5%) of our patients experienced mild COVID-19 infection, 19 (5.9%) suffered from respiratory insufficiency, and seven (2.2%) required admission to the intensive care unit (ICU). Non-compliance to medication was recorded at 25.2%. There were 115 (35.5%) patients who had an AIRD flare that was significantly higher among those who were not adherent to the medications (p<0.001). Disease flare was also significantly seen among patients who were not on prednisone or were on low doses of prednisone (p<0.001). The majority (n=33, 97.1%) of the 34 infected patients who had an AIRD flare had their flare-up at the same time as their COVID-19 infection (p<0.001). COVID-19 vaccination rate was 87.7% (n=284). The most common reason for non-vaccination in 40 (12.3%) patients was the patients' concern about disease flare-ups by the vaccine or interference of the vaccine with their medication (n=16, 4.9%).

CONCLUSION

Our study showed a 35.5% (n=115) COVID-19 infection rate. The majority of our AIRD patients sustained minor infections that did not require hospitalization or ICU admission. The majority of the patients who underwent a severe COVID-19 infection course were not on prednisolone or were on low-dose prednisone. Due to COVID-19 restrictions and drug shortages, one in four patients (25.3%) stopped taking their medications and was significantly found to have a high prevalence of underlying AIRD flare. Despite the high vaccination rate, disease flare was the biggest concern for those who were not immunized. Although the COVID-19 pandemic has ended, doctors should be aware of risk factors associated with severe AIRD outcomes that should be balanced based on the infection severity, underlying disease flares, and patient-centered education about medication adherence and vaccination.

Sexual and reproductive health while living with rheumatoid arthritis: The impact of the disease stage on patient perspectives

BACKGROUND

Rheumatoid arthritis (RA) is one of the most prevalent rheumatic diseases that harms all aspects of patients' lives, including sexual and reproductive health (SRH), often neglected in patients' care. The study aimed to explore the sexual and reproductive experiences of Mexican outpatients with RA from a narrative perspective.

PATIENTS AND METHODS

From July 2020 to October 2021, 30 adult patients with RA from the Department of Immunology and Rheumatology outpatient clinic of a national referral center for rheumatic diseases had in-depth interviews audiotaped, transcribed, and analyzed using a thematic analysis approach. Results are presented in a descriptive and interpretative manner and integrated into a theoretical model for the topic understanding.

RESULTS

Five intertwined major themes emerged: I) RA onset: Absence of SRH contents, II) Healthcare for RA: Emerging SRH contents, III) RA's impact: Proliferation of SRH contents, IV) Coping with the process of living with RA: SRH-related strategies, and V) The impact of the COVID-19 pandemic on patients' experiences: Increased SRH burden. SRH contents emerged through these major themes (but at RA onset), mostly when inquired and mainly when narrating the RA impact and coping. Patients identified that RA affected their couple dynamics, sexual function, and reproductive project. The SRH care was considered relevant but limited and focused on reproductive contents. It worsened during the COVID-19 pandemic. We proposed a theoretical model where patients' SRH experiences are embedded across their RA biography and integrated with the RA impact and the copy with the disease process. These intertwined experiences were also evident during the COVID-19 pandemic, which challenged participants' biopsychosocial resources.

CONCLUSIONS

The sexual and reproductive experiences narrated by the RA outpatients concerning their disease-related biography showed that even when the SRH appeared as not prioritized at the disease onset, it was widely expressed during the process of living and coping with the disease and was additionally affected by the COVID-19 pandemic.

Influence of the COVID-19 Pandemic on Medical Management and on Healthcare Delivery of Immune-Mediated Rheumatic and Musculoskeletal Diseases during the First Pandemic Period February to July 2020: A Systematic Review

(1) Background and Objectives: The COVID-19 pandemic influenced the management of patients with immune-mediated rheumatic and musculoskeletal diseases (imRMDs) in various ways. The goal of our systematic review was to determine the influence of the first period of the COVID-19 pandemic (February 2020 to July 2020) on the management of imRMDs regarding the availability of drugs, adherence to therapy and therapy changes and on healthcare delivery. (2) Materials and Methods: We conducted a systematic literature search of PubMed, Cochrane and Embase databases (carried out 20-26 October 2021), including studies with adult patients, on the influence of the COVID-19 pandemic on the management of imRMDs. There were no restrictions regarding to study design except for systematic reviews and case reports that were excluded as well as articles on the disease outcomes in case of SARS-CoV-2 infection. Two reviewers screened the studies for inclusion, and in case of disagreement, a consensus was reached after discussion. (3) Results: A total of 5969 potentially relevant studies were found, and after title, abstract and full-text screening, 34 studies were included with data from 182,746 patients and 2018 rheumatologists. The non-availability of drugs (the impossibility or increased difficulty to obtain a drug), e.g., hydroxychloroquine and tocilizumab, was frequent (in 16-69% of patients). Further, medication non-adherence was reported among patients with different imRMDs and between different drugs in 4-46% of patients. Changes to preexisting medication were reported in up to 33% of patients (e.g., reducing the dose of steroids or the cessation of biological disease-modifying anti-rheumatic drugs). Physical in-office consultations and laboratory testing decreased, and therefore, newly implemented remote consultations (particularly telemedicine) increased greatly, with an increase of up to 80%. (4) Conclusions: The COVID-19 pandemic influenced the management of imRMDs, especially at the beginning. The influences were wide-ranging, affecting the availability of pharmacies, adherence to medication or medication changes, avoidance of doctor visits and laboratory testing. Remote and telehealth consultations were newly implemented. These new forms of healthcare delivery should be spread and implemented worldwide to routine clinical practice to be ready for future pandemics. Every healthcare service provider treating patients with imRMDs should check with his IT provider how these new forms of visits can be used and how they are offered in daily clinical practice. Therefore, this is not only a digitalization topic but also an organization theme for hospitals or outpatient clinics.

Post-stroke rehabilitation in the peri-pandemic COVID-19 era

The coronavirus disease 2019 (COVID-19), which arose in late 2019, caused extensive destruction, impacting a substantial proportion of the worldwide population and leading to millions of deaths. Although COVID-19 is mainly linked to respiratory and pulmonary complications, it has the potential to affect neurologic structures as well. Neurological involvement may manifest as minimal and reversible; however, a notable proportion of cases have exhibited pronounced neurological consequences, such as strokes. Endothelial inflammation, hypercoagulation, renin-angiotensin-aldosterone system alterations, and cardiogenic embolism are the pathophysiological mechanisms of stroke under COVID-19 circumstances. Physical activity and exercise have improved several aspects of post-stroke recovery, including cardiovascular health, walking capacity, and upper limb strength. They are commonly used to assist stroke survivors in overcoming their motor restrictions. Furthermore, stroke rehabilitation can incorporate a range of specific techniques, including body-weight-supported treadmill applications, constraint-induced movement therapy, robotic rehabilitation interventions, transcranial direct current stimulation, transcranial magnetic stimulation, and prism adaptation training. Under pandemic conditions, there were several barriers to neurological rehabilitation. The most significant of these were individual's fear of infection, which caused them to postpone their rehabilitation applications and rehabilitation areas being converted into COVID-19 units. The primary emphasis had turned to COVID-19 treatment. Several valuable data and views were gained in reorganizing rehabilitation during the pandemic, contributing to establishing future views in this regard.

Assessing the Impact of COVID-19 Vaccines on Sickle Cell Anaemia Patients: A Comparative Analysis of Biochemical and Haematological Parameters

The coronavirus disease 2019 (COVID-19) vaccines have been developed to help prevent the spread of the virus infections. The COVID-19 vaccines, including Pfizer, Moderna, and AstraZeneca, have undergone rigorous testing and have demonstrated both safety and effectiveness. Extensive evidence supports their effectiveness in preventing severe illness, hospitalization, and mortality associated with COVID-19 infection. The administration of COVID-19 vaccines can directly affect hematological and biochemical parameters, with reported cases showing an association with thrombosis and thrombocytopenia. Therefore, it was hypothesized that COVID-19 vaccines may also influence hematological and biochemical markers in sickle cell patients. This study aimed to investigate the side effects of COVID-19 vaccines on sickle cell patients, providing a comprehensive evaluation of hematological and biochemical parameters. To our knowledge, this is the first study of its kind conducted in Saudi Arabia. The study included the evaluation of Pfizer and Oxford-AstraZeneca vaccines in sickle cell patients, measuring key parameters. Our findings revealed varying impacts of both vaccines on the ALT, AST, and CRP levels. Notably, CRP and ALT exhibited potential as indicators for renal disease, diabetes, and arthritis. However, further investigations are necessary to uncover the underlying mechanisms that drive these observed differences and comprehend their clinical implications for this vulnerable patient population. The unique nature of our study fills a crucial research gap and underscores the need for additional research in this area.

Has the COVID 19 Pandemic Impacted the Management of Chronic Musculoskeletal Pain?

PURPOSE OF REVIEW

The COVID-19 pandemic has affected the management of chronic musculoskeletal pain; however, the extent of its impact has not been established. We conducted a comprehensive review of the pandemic's impact on clinical outcomes and healthcare accessibility for osteoarthritis (OA), rheumatoid arthritis (RA), fibromyalgia (FM), lower back pain (LBP), and other musculoskeletal disorders and chronic pain syndromes to better inform clinical decision-making.

RECENT FINDINGS

We examined 30 studies (n = 18,810) from 36 countries investigating the impact of the COVID-19 pandemic on chronic musculoskeletal pain outcomes. The available evidence suggests that the pandemic significantly impacted pain levels, mental health, quality of life and healthcare accessibility in patients with chronic musculoskeletal pain. Of 30 studies, 25 (83%) reported symptom worsening, and 20 (67%) reported reduced healthcare accessibility. Patients were unable to access necessary care services during the pandemic, including orthopedic surgeries, medications, and complementary therapies, leading to worsened pain, psychological health, and quality of life. Across conditions, vulnerable patients reported high pain catastrophizing, psychological stress, and low physical activity related to social isolation. Notably, positive coping strategies, regular physical activity, and social support were associated with positive health outcomes. Most patients with chronic musculoskeletal pain had greatly affected pain severity, physical function, and quality of life during the COVID-19 pandemic. Moreover, the pandemic significantly impacted treatment accessibility, preventing necessary therapies. These findings support further prioritization of chronic musculoskeletal pain patient care.

Comorbidities in the COVID-19 Pandemic: Scopus-Based Bibliometric Analysis

BACKGROUND

Comorbidities attract enormous attention amid the coronavirus disease 2019 (COVID-19) pandemic. Mapping knowledge based on these clinical conditions is increasingly important since the pandemic is still raging and primarily affecting subjects with chronic diseases and comorbidities. Clinical presentation and complications of COVID-19 are still hot topics which are explored in numerous evidence-based publications. The aim of this study was to analyze Scopus-indexed COVID-19 papers covering comorbidities.

METHODS

Searches through the Scopus database were performed on September 19, 2022 using the following keywords: "Diabetes mellitus" OR "Cardiovascular Diseases" OR "Rheumatic Diseases" OR "Obesity" OR "Malignancies" AND "COVID-19." All retrieved articles were analyzed using the following categories: document type, authorship, keywords, journal, citation score, country of origin, and language. Using the software tool VOSviewer version 1.6.18, we visualized the network of authors and keywords co-occurrence of the most prevalent comorbidities reported in connection with COVID-19.

RESULTS

Reports on COVID-19 and diabetes mellitus (DM) were most frequently published (n = 12,282). The US was the most productive country (n = 3,005) in the field of COVID-19 and comorbidities. There were 1,314 documents on COVID-19 and rheumatic diseases which is the least number in comparison with other comorbidities (COVID-19 and DM: 12,282, COVID-19 and cardiovascular disease: 9,911, COVID-19 and obesity: 7,070, and COVID-19 and malignancies: 1,758).

CONCLUSION

This mapping of COVID-19-related documents in connection with comorbidities may prioritize future research directions.

Rituximab, a Safer Option for Rheumatoid Arthritis: A Comparison of the Reported Adverse Events of Approved Monoclonal Antibodies

Background & Objectives

Monoclonal antibodies (mAbs), which are commonly used to treat rheumatoid arthritis (RA), have been linked to a variety of adverse events (AEs). The objective of the study was to compare the safety profiles of six FDA-approved mAbs (sarilumab, tocilizumab, adalimumab, golimumab, infliximab, and rituximab) marketed for the treatment of RA.

Methods

A systematic review of the literature was conducted using the databases PubMed, Cochrane Library, and Science Direct. The manuscript comprised a total of 23 clinical studies. The percentage of patients who had AEs was calculated and presented using box-whisker and forest plots.

Results

Infections and infestations were found to be the most common AEs in RA patients treated with mAbs. Raised alanine aminotransferase (ALT), aspartate aminotransferase (AST), upper respiratory tract infection (URTI), and nasopharyngitis were frequently reported. The most common AEs were reported with adalimumab. The highest percentage of patients reporting AEs was associated with golimumab (52%), while rituximab had the fewest AEs (4.9%).

Conclusion

In conclusion, rituximab appears to be a safer treatment option for RA as it is found to be associated with a lower risk of AEs, particularly respiratory infections.

Tight control in patients with rheumatoid arthritis treated with targeted therapies across the COVID-19 pandemic era

OBJECTIVES

To analyze the impact of different patterns of healthcare delivery on remission of rheumatoid arthritis (RA) patients treated with targeted therapies during the first wave (2020) and second/third waves (2021) of the pandemic compared to the pre-pandemic period (2019).

METHODS

In this observational real-life study, data from RA patients treated with biologic or targeted synthetic drugs were extracted from a longitudinal registry. Clinical Disease Activity Index (CDAI) was analyzed in the same period from the 22nd of February to the 18th of May for three consecutive years. These three periods were characterized by different patterns of healthcare delivery: (1) before the pandemic (2019) only in-person visits, (2) during the first wave (2020) both in-person visits and telehealth, and (3) during the second/third waves (2021) only in-person visits. A generalized linear model with the binomial error was fitted to evaluate the difference in the proportion of patients in CDAI remission. Quantile regression was used to compare the median of CDAI in difficult-to-treat (D2T) patients.

RESULTS

In the three periods, we included 407, 450, and 540 RA patients respectively. The percentages of patients in CDAI remission were similar in the three periods (prevalence ratio 1.07, p value 0.423 between 2020 and 2019, and 1.01, p-value 0.934 between 2021 and 2019). The CDAI remission rate was 40.55% (N = 163), 43.18% (N = 155) and 40.82% (N = 220) in 2019, 2020 and 2021, respectively. Among our cohort of D2T patients, CDAI remission was similar across the three periods (N = 30, 22.22%; N = 27, 23.68%; and N = 34, 21.52% respectively).

CONCLUSION

Although the pandemic has imposed changes in our healthcare delivery, these different strategies seem to be effective in ensuring satisfactory management of RA treated with targeted therapies. The approaches modulated in the context of the different periods have been a feasible compensation for ensuring disease control even in D2T patients.

A scoping review of non-professional medication practices and medication safety outcomes during public health emergencies

OBJECTIVES

Public health emergencies (PHE) can disrupt personal medication practices and increase the risk of medication-related harm and other negative medication-related outcomes. Our aim was to examine the extent and nature of published research on this topic to guide future research and practice.

STUDY DESIGN

Scoping review.

METHODS

Standard electronic databases were searched. PRISMA-ScR guidelines were followed. Extracted data were organised in response to review questions and narrative accounts developed.

RESULTS

A total of 129 studies were included, conducted across 32 countries, mostly in the USA (n = 42). Sixty-eight (53%) reported on infectious events, 49 (39%) climatological or ecological events and the remainder a mixture of terrorism, war or other disasters. The studies described several medication safety outcomes (medication-related harm, adherence, supply) and adaptive medication practices (self-altering prescribed medications, sharing medications and changing healthcare providers). Challenges to maintaining routine medication practices during a PHE included transport, finance, quarantine and knowledge-related issues. Twenty-eight studies (22%) examined health inequalities pertaining to adverse medication-related outcomes, with findings suggesting that gender, age, ethnicity, educational and socio-economic status may be related to inequalities. Research gaps identified included carers', children's and minority communities' experiences and intervention studies.

CONCLUSIONS

There is considerable evidence of disruptions to routine personal medication practices during PHEs and of medication-related harm and other negative outcomes. Maintaining medication supply for the management of chronic conditions is a universal problem across all emergency types. Research is needed to address these disruptions, particularly amongst people who experience health inequalities who may need additional support.

Impact of the COVID-19 pandemic on prescription refills for immune-mediated inflammatory disorders: a time series analysis (January 2019 to January 2021) using the English Prescribing Dataset

OBJECTIVE

To investigate monthly prescription refills for common immunosuppressive/immunomodulatory therapy (sulfasalazine, hydroxychloroquine, azathioprine, methotrexate, leflunomide) prescriptions in England during the complete first wave of the COVID-19 pandemic. Secondary analysis examined unit cost analysis and regional use.

DESIGN AND SETTING

A national cohort of community-based, primary care patients who anonymously contribute data to the English Prescribing Dataset, dispensed in the community in England, were included. Descriptive statistics and interrupted time series analysis over 25 months (14 months before, 11 months after first lockdown) were evaluated (January 2019 to January 2021, with March 2020 as the cut-off point).

OUTCOME MEASURES

Prescription reimbursement variance in period before the pandemic as compared with after the first lockdown.

RESULTS

Fluctuation in monthly medicines use is noted in March 2020: a jump is observed for hydroxychloroquine (Mann-Whitney, SE 14.652, standardised test statistic 1.911, p value=0.059) over the study period. After the first lockdown, medicines use fluctuated, with wide confidence intervals. Unit-cost prices changed substantially: sulfasalazine 33% increase, hydroxychloroquine 98% increase, azathioprine 41% increase, methotrexate 41% increase, leflunomide 20% decrease. London showed the least quantity variance, suggesting more homogeneous prescribing and patient access compared with Midlands and East of England, suggesting that some patients may have received medication over/under requirement, representing potential resource misallocation and a proxy for adherence rates. Changepoint detection revealed four out of the five medicines' use patterns changed with a strong signal only for sulfasalazine in March/April 2020.

CONCLUSIONS

Findings potentially present lower rates of adherence because of the pandemic, suggesting barriers to care access. Unit price increases are likely to have severe budget impacts in the UK and potentially globally. Timely prescription refills for patients taking immunosuppressive/immunomodulatory therapies are recommended. Healthcare professionals should identify patients on these medicines and assess their prescription-day coverage, with planned actions to flag and follow-up adherence concerns in patients.

Rapid Review of Medication Taking (Adherence) Among Patients With Rheumatic Diseases During the COVID-19 Pandemic

OBJECTIVE

We aimed to identify, appraise, synthesize, and contextualize rapidly emerging reports on medication taking (adherence) among patients with rheumatic diseases during the COVID-19 pandemic.

METHODS

We searched MEDLINE, EMBASE, and CINAHL for peer-reviewed communications, letters, and articles published during the COVID-19 pandemic evaluating medication taking among individuals with rheumatic diseases. We appraised assessment and reporting of medication adherence according to established definitions of 3 distinct problems of medication taking (i.e., noninitiation, poor implementation, and discontinuation) and pooled findings using random-effects models.

RESULTS

We included 31 peer-reviewed studies in our synthesis from various jurisdictions, of which 25 described medication taking among rheumatology patients and 6 described medication prescribing among rheumatology providers. The pooled prevalence of overall medication nonadherence was 14.8% (95% confidence interval [95% CI] 12.3-17.2) and that of medication discontinuation (i.e., stopping of prescriptions) and poor implementation (i.e., not taking medication at the dose/frequency prescribed) as 9.5% (95% CI 5.1-14.0) and 9.6% (95% CI 6.2-13.0), respectively. Noninitiation (i.e., not starting/not filling new prescriptions) was not addressed.

CONCLUSION

Medication taking among individuals with rheumatic diseases during the COVID-19 pandemic varies globally. Unclear reporting and extensive variation in research methods between studies create barriers to research replication, comparison, and generalization to specific patient populations. Future research in this area should use consistent and transparent approaches to defining and measuring medication taking problems to ensure that findings appropriately describe the epidemiology of medication adherence and have the potential to identify modifiable targets for improving patient care.

Impact of Perceived Stress During the SARS-CoV-2 Pandemic on Rheumatoid Arthritis Patients' Disease Activity: An Online Survey

INTRODUCTION/OBJECTIVES

Psychological stress worsens rheumatoid arthritis (RA) disease activity, and the COVID-19 pandemic has increased stress/anxiety in rheumatic patients. The purpose of this study was to determine if stress during the COVID-19 pandemic specifically impacts RA disease activity as reported by the patient.

METHOD

This was a cross-sectional COVID-19 RA survey study. University of California, Los Angeles rheumatology clinic patients were emailed a link to a survey in July and November 2020. The 30-question survey pertained to COVID-19-related stress, RA disease activity, and demographics. For the survey responders, anti-cyclic citrullinated antibody, rheumatoid factor, and age were extracted from the electronic health record. Analyses were performed to examine the association between the 4-item Perceived Stress Scale (PSS-4) and other COVID-19-related stress measures with the Routine Assessment of Patient Index Data 3 (RAPID3).

RESULTS

A total of 1138/5037 subjects completed the emailed survey (22.6% response rate). When examining responses across RAPID3 categories (near remission, low, moderate, and high disease severity), there were significant increases in PSS-4 and other stress variables. Multiple linear regression models showed that PSS-4, financial stress, age, seropositivity, disease duration, and Black race were independently associated with worsened RAPID3 scores, when controlling for other confounding factors.

CONCLUSIONS

This study suggests that stress overall negatively impacts RAPID3, and Black RA patients had a higher RAPID3 scores during the COVID-19 pandemic. Despite colossal efforts to combat the pandemic, RA patients currently suffer from stress/anxiety, and methods to mitigate these psychological effects are needed.

The Flare of Rheumatic Disease After SARS-CoV-2 Vaccination: A Review

As the coronavirus disease 2019 (COVID-19) pandemic continues worldwide, vaccination has been considered an effective measure to protect people from the COVID-19 and end the pandemic. However, for patients with rheumatic diseases (RD), concern for the induction of RD flare may combat the enthusiasm for vaccination. In general, current evidence doesn’t support the increased risk of disease flare after COVID-19 vaccination. However, the disease flare of RDs may be triggered by COVID-19 vaccinations, especially for patients with high disease activity. Most of these flares after vaccination are mild and need no treatment escalation. Considering the benefits and risks, RD patients are recommended to receive the COVID-19 vaccination but should be vaccinated when the RDs are in stable states.

Medication Adherence of Vietnamese Outpatients with Chronic Diseases during the COVID-19 Pandemic

The purpose of this study was to determine the medication adherence of outpatients with chronic diseases and the association between both patient attitudes and preventive practices regarding COVID-19 and their medication adherence. We performed a cross-sectional study in Vietnam. Medication adherence was determined using the translated and validated Vietnamese version of the General Medication Adherence Scale (GMAS). Patient attitudes and preventive practices regarding COVID-19 were measured using the 5K message of the Vietnam Ministry of Health (facemasks, disinfection, distance, no gatherings, health declarations). The associations between patient characteristics and medication adherence were determined by multivariable regression. The study included 1852 outpatients, and 57.6% of the patients adhered to their medications. Patients who recognized the pandemic’s obstruction of medical follow-ups (OR = 1.771; 95%CI = 1.461−2.147; p < 0.001), who applied ≥2 preventive methods (OR = 1.422; 95%CI = 1.173−1.725; p = 0.001), who were employed (OR = 1.677; 95%CI = 1.251−2.248; p = 0.001), who were living in urban areas (OR = 1.336; 95%CI = 1.090−1.637; p = 0.005,) who possessed higher education levels (OR = 1.313; 95%CI = 1.059−1.629; p = 0.013), or who had ≤2 comorbidities (OR = 1.293; 95%CI = 1.044−1.600; p = 0.019) were more likely to adhere to their medications. The adherence percentage for outpatients with chronic diseases was quite low during the pandemic. Patients who did not recognize the COVID-19 pandemic’s obstruction of medical follow-ups or who had poor preventive practices were less likely to adhere to medications. Healthcare providers should pay more attention to these groups to achieve desired treatment outcomes.

Rheumatoid arthritis occurring after coronavirus disease 2019 (COVID-19) infection: Case based review

Introduction

Rheumatoid arthritis (RA) is a multifactorial disease. Genetic predisposition and environmental triggers including infections are the major players of autoimmunity. We present a case of rheumatoid arthritis occurring after the coronavirus disease 2019(COVID-19) infection.

Case presentation

A 72-year-old woman with a medical history of hypertension and atrial fibrillation presented for a 2-month history of bilateral symmetric polyarthritis starting 2 weeks after asymptomatic COVID-19 infection. Physical examination showed swelling and tenderness of the metacarpophalangeal and proximal interphalangeal joints, wrists, and knees. She had increased inflammatory biomarkers (C-reactive protein:108 mg/L, erythrocyte sedimentation rate: 95 mm, alpha-2 and gamma-globulins, interleukin 6: 16.5 pg/mL). Immunological tests revealed positive rheumatoid factor (128 UI/mL), anti-cyclic citrullinated peptide antibodies (200UI/mL), anti-nuclear antibodies (1:320), and anti-SARS-CoV-2 IgG (12.24U/mL). She had the genotype: HLA-DRB1*04:11, HLA-DQB1*03:01, and HLA-DQB1* 03:02. Hands and feet radiographs did not show any erosion. Ultrasonography showed active synovitis and erosion of the 5th right metatarsal head. The diagnosis of RA was made. The patient received intravenous pulses of methylprednisolone (250 mg/day for 3 consecutive days) then oral corticosteroids (15 mg daily) and methotrexate (10 mg/week) were associated, leading to clinical and biological improvement.

Conclusion

Despite its rarity, physicians should be aware of the possibility of the occurrence of RA after COVID-19 infection. This finding highlights the autoimmune property of this emerging virus and raises further questions about the pathogenesis of immunological alterations.

Frequency, characteristics and outcome of corona virus disease 2019 (COVID-19) infection in Iranian patients with rheumatic diseases

Aim of the work

To investigate the frequency, clinical characteristics and outcome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in rheumatic diseases patients.

Patients and methods

One thousand patients with rheumatic diseases including systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (SpA), systemic sclerosis (SSc), Sjögren's syndrome (SS), Behçets disease (BD), vasculitis, idiopathic inflammatory myositis (IIM), relapsing polychondritis, sarcoidosis and antiphospholipid syndrome (APS) were studied. The following data were collected: age, sex, disease diagnosis, rheumatic disease medication. Rheumatic diseases patients were divided into two groups of infected and non-infected patients with COVID-19 and collected data were compared.

Results

The 1000 patients mean age was 43.4 ± 13 years and 84.1% were females. The main diagnosis was RA (37.1%), followed by SLE (23.8%), SpA (13.4%), SSc (12.4%), vasculitis, BD and rhupus in 2.4%, 2.3% and 2.2% respectively, SS and SSc in 0.7% each. Most patients were taking glucocorticoids (78.4%). A large majority of patients were taking at least one of the cDMARDs. 16.1% were taking biologic therapy. 221 rheumatic diseases patients with COVID-19 were identified. Of these, 38 patients (17.2%) were hospitalized and 9 patients (4.1%) died. No significant difference was observed for compared variables in patients with and without COVID-19 except for prednisolone >20 mg/d (0.64% vs 2.26%; p = 0.048).

Conclusion

Most rheumatic diseases do not seem to be a risk factor for developing COVID-19 infection and despite immunosuppressive therapies, there is no poorer outcome. Only, patients using prednisolone >20 mg/d are at higher risk of developing COVID-19 infection.

Clinical course, chest computed tomography severity score and outcome of coronavirus disease 2019 (COVID-19) in patients with rheumatic diseases

Aim of the work

To assess the clinical manifestations, imaging findings and outcomes of corona virus disease 2019 (COVID-19) in patients with rheumatic diseases.

Patients and methods

In a three-center study, patients with rheumatic diseases who developed COVID-19 were included. Patients were classified into two groups, i) inflammatory arthritis including rheumatoid arthritis (RA), spondyloarthritis (SpA) and undifferentiated arthritis, ii) connective tissue diseases (CTDs) including systemic lupus erythematosus (SLE), vasculitis and others. COVID-19 outcomes were assessed based on chest computed tomography severity score (CT-ss), the level of care, the number of patients who died and flare of underlying rheumatic disease.

Results

One hundred ninety-six patients with a mean age of 47.9 ± 15.1 years, 73.5% female, were included. Underlying rheumatic diseases were RA (57.7%), SLE and other CTDs (17.9%), SpA (11.2%), vasculitis (11.2%) and undifferentiated arthritis (2%). Myalgia, malaise and fever were the most common clinical manifestations of COVID-19. Pneumonia on computerized tomography (CT), hospitalization, admission in intensive care unit and need to mechanical ventilation were observed in 75.5, 37.2%, 10.7% and 6.6% of patients, respectively. Treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, diabetes and underlying pulmonary disease were predictors of moderate to severe pneumonia and hospitalization. Fifteen (7.6%) patients died. Flare of underlying rheumatic disease occurred in 16.3% of patients. Flare of disease in patients with CTDs was significantly more than other rheumatic diseases.

Conclusions

In rheumatic patients, treatment with NSAIDs or prednisolone, diabetes and pulmonary disease are risk factors of moderate to high CT-ss and hospitalization during COVID-19.

COVID-19 outcomes among rheumatic disease patients in Kuwait: Data from the COVID-19 Global Rheumatology Alliance (C19-GRA) physician registry

PURPOSE

We aimed to assess the characteristics of inflammatory rheumatic disease (IRD) patients in Kuwait diagnosed with COVID-19 and the factors linked with hospitalization, complications, and mortality.

METHODS

Data of IRD patients from Kuwait diagnosed with COVID-19 between March 2020 and March 2021, submitted to the COVID-19 Global Rheumatology Alliance physician-reported registry, were included in our analysis. Data on patients' age, gender, smoking, diagnosis, IRD activity, and other comorbidities were collected. Statistical Package for the Social Sciences (SPSS), version 25, was used for statistical analysis.

RESULTS

A total of 52 patients were included, with a mean age of 55 years (±14). The majority of patients were ≤65 years (77%), female (77%), non-smokers (80.8%), and diagnosed with rheumatoid arthritis (67.0%). Of the included patients, 19.2%, 9.6%, and 7.7% reported having methotrexate monotherapy, antimalarials monotherapy, and interleukin-6 inhibitors monotherapy immediately before COVID-19, respectively. Most of the included patients (92.3%) were either in remission or had minimal/low disease activity, while others (7.7%) had moderate disease activity. Forty-three patients (82.7%) were hospitalized, while 11 patients (25.6%) required ventilation (invasive or non-invasive). Ten of the ventilated patients (90.9%) received glucocorticoids as part of the local protocol to treat severe COVID symptoms, and 4 patients (7.69%) died. The duration till symptom-free ranged between 0 to 30 days, with a mean value of 10 days (±6.5).

CONCLUSION

The current study provides timely real-world evidence regarding characteristics and potential risk factors linked to poor COVID-19-related outcomes in the IRD population in Kuwait.

The Emerging Era of Interventional Imaging in Rheumatology: An Overview During the Coronavirus Disease-2019 (COVID-19) Pandemic

Imaging has long been taking its place in the diagnosis, monitor, and prognosis of rheumatic diseases. It plays a vital role in the appraisal of treatment. Key progress in the clinical practice of rheumatology is the innovation of advanced imaging modalities; such as musculoskeletal ultrasound (MSUS), computerized tomography (CT) and magnetic resonance imaging (MRI). These modalities introduced a promising noninvasive method for visualizing bone and soft tissues to enable an improved diagnosis. The use of MSUS in rheumatology is considered a landmark in the evolution of the specialty and its ease of use and many applications in rheumatic diseases make it a forerunner instrument in the practice. The use of MSUS among rheumatologists must parallel the development rate of the excellence revealed in the specialty. Moreover, innovative interventional imaging in rheumatology (III-R) is gaining fame and key roles in the near future for a comprehensive management of rheumatic diseases with precision. This review article throws light on the emergence of these robust innovations that may reshape the guidelines and practice in rheumatology, in particular, efforts to enhance best practice during the coronavirus disease 2019 (COVID-19) pandemic are endorsed.

Hydroxychloroquine non-availability during COVID-19 pandemic and its relation to anxiety level and disease activity in rheumatoid arthritis and lupus patients: a cross-sectional study

Background

During COVID-19 disease era, there is an accelerated demand for hydroxychloroquine since it was suggested by some centers as potential therapy for COVID-19 which has led to diminished supplies for patients with rheumatic disease and which carried unexpected risk for disease flare particularly in patients with systemic lupus erythematosus and rheumatoid arthritis. The purpose of the work is to detect the effect of HCQ shortage in patients with RA and SLE on anxiety and disease activity.

Results

A total of 320 patients were divided into two groups: group 1—216RA patients with mean age 45.5 ± 9.59 years, disease duration 43.4 ± 25.6 months with female predominance (62.5%). Group 2—104 SLE patients with mean33.4 ± 7.9 age years, disease duration 52.1 ± 34.6 months with female predominance (85.6%). HCQ shortage occurred in 174 RA patients (80.5%) and 76 lupus patients (73.1%). Despite HCQ shortage, there were no significant change in disease activity of RA (using CDAI) and SLE (using SELENA) p = 0.063 and 0.064 respectively before and after HCQ shortage. Anxiety level was higher in patients who were exposed to HCQ shortage in both groups (SLE p 0.0058 and RA p 0.0044) when we compared them to those without HCQ shortage.

Conclusion

In most patients with RA and SLE, the COVID-19 pandemic resulted in a HCQ scarcity, with no effect on disease activity. Anxiety was found to be associated with HCQ shortage in both diseases.

Factors influencing access and utilization of health services among older people during the COVID - 19 pandemic: a scoping review

BACKGROUND

Access to healthcare and service utilization are both considered essential factors for improving the general health and wellbeing of older people, especially at the time of COVID-19 pandemic. The aim of the study is to explore factors affecting healthcare access and health service utilization for older people during the pandemic.

METHODS

PubMed, Web of Science, Scopus and Embase were systematically searched for relevant articles. Access, utilization, health, elderly and COVID-19 were used as keywords in the search strategy. A total of 4308 articles were identified through the initial database search; 50 articles were included in the review as passing the eligibility criteria. The searches were conducted up to August 2021. Data extraction was performed, and evidence was descriptively illustrated. Thematic analysis was used to explore factors influencing the elderly's access and utilization of healthcare services, using Max QDA10, a qualitative analysis software.

RESULTS

Among articles included in the review (n = 50), a majority of the studies were from the United States (36%), followed by India (8%). According to the main healthcare services, a large number of articles (18%) were related to mental health services, followed by digital health services (16%). Factors were identified at an individual, provider and systems level. Seven main themes emerged from the thematic analysis, as determinants of elderly's access and utilization of healthcare services during COVID-19 pandemic. These included: access to non-COVID related services, access to COVID-related services, literacy and education, accommodation challenges, perceived attitudes of aging, and policies and structures, and social determinants.

CONCLUSION

Mental health and digital health services were identified as major issues influencing or contributing to or influencing older people's health during the COVID-19 pandemic. We also argue on the importance of a rounded view, as attention to a range of factors is vital for policy decisions towards sustainable care and equitable interventions for improving the health of older people.

Rheumatology university faculty opinion on coronavirus disease-19 (COVID-19) vaccines: the vaXurvey study from Egypt

OBJECTIVES

The aim of the present work was to explore the perspectives of Egyptian Rheumatology staff members as regards the coronavirus disease-19 (COVID-19) vaccine.

METHODS

The survey is composed of 25 questions. Some questions were adapted from the global rheumatology alliance COVID-19 survey for patients.

RESULTS

187 rheumatology staff members across Egypt from 18 universities and authorizations actively participated with a valid response. The mean time needed to complete the survey was 17.7 ± 13 min. Participants were 159 (85%) females (F:M 5.7:1). One-third agreed that they will be vaccinated once available, 24.6% have already received at least one dose, 29.4% are unsure while 16% will not take it. Furthermore, 70.1% agreed that they will recommend it to the rheumatic diseases (RD) patients once available, 24.1% are not sure while 5.9% will not recommend it. RD priority to be vaccinated against COVID-19 in descending order include SLE (82.9%), RA (55.1%), vasculitis (51.3%), systemic sclerosis (39.6%), MCTD (31.6%), Behcet's disease (28.3%). The most common drugs to be avoided before vaccination included biologics (71.7%), DMARDs (44.4%), biosimilars (26.7%), IVIg (17.1%) and NSAIDs (9.1%).

CONCLUSIONS

The results of the study and specifically the low rate of acceptability are alarming to Egyptian health authorities and should stir further interventions to reduce the levels of vaccine hesitancy. As rheumatic disease patients in Egypt were not systematically provided with the vaccine till present, making the vaccine available could as well enhance vaccine acceptance. Further studies to investigate any possible side effects, on a large scale of RD patients are warranted.

Challenges of Egyptian patients with systemic lupus erythematosus during the COVID-19 pandemic

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic in Egypt is part of the worldwide COVID-19 pandemic that has contributed to substantial deterioration of healthcare systems. The aim of this study was to assess the challenges faced by Egyptian systemic lupus erythematosus (SLE) patients during the COVID-19 pandemic.

MATERIAL AND METHODS

This questionnaire-based study was carried out on 200 patients with SLE from Egypt. The questionnaire provided covered socioeconomic status, lupus disease data, information about COVID-19 infection, and medical and family history of COVID-19 infection.

RESULTS

The mean age of the participants was 30.1 ±8.4 years. 140/200 (70%) of the participants reported difficulty in obtaining medications during the COVID-19 pandemic, particularly antimalarials (60%). The lupus disease condition became worse because of the drug shortage in half of the participants. Wearing protective masks (74%) and using disinfectants of the hands several times per day (67%) were the most reported used measures. Forty patients (20%) had to stop or reduce taking nonsteroidal anti-inflammatory drugs while 10 patients (5%) had to start taking antimalarials as a prophylaxis against COVID-19 infection. Among those who needed hospitalization, the main cause was lupus activity, and most of them (71%) experienced difficulty in hospital admission. Thirty-two patients (16%) had confirmed COVID-19 infection. About half of them had lupus flare and had to change the medications used for treatment of lupus.

CONCLUSIONS

The current COVID-19 pandemic has a negative impact on the healthcare provided to SLE patients in Egypt. Patients with SLE faced a shortage of their medications, especially antimalarials, and difficulty in hospital admission.

Clinical and bioethical implications of health care interruption during the COVID-19 pandemic: A cross-sectional study in outpatients with rheumatic diseases

BACKGROUND

To determine the impact of health care interruption (HCI), on clinical status of the patients reincorporated to an outpatient clinic for rheumatic diseases (OCDIR), from a tertiary care level center who was temporally switched to a dedicated COVID-19 hospital, and to provide a bioethical analysis.

METHODS

From March to June 2020, the OCDIR was closed; since June, it is limited to evaluate 25% of the ongoing outpatients. This cross-sectional study surveyed 670 consecutive rheumatic outpatients between June 24th and October 31th, concomitant to the assessment of the rheumatic disease clinical status by the attendant rheumatologist, according to disease activity level, clinical deterioration and adequate/inadequate control. Multiple logistic regression analysis identified factors associated to HCI and to clinical deterioration.

RESULTS

Patients were middle-aged females (86.7%), with median disease duration of 10 years, comorbidity (38.5%) and 138 patients (20.6%) had discontinued treatment. Primary diagnoses were SLE and RA, in 285 (42.5%) and 223 (33.3%) patients, respectively. There were 344 patients (51.3%) with HCI. Non-RA diagnosis (OR: 2.21, 95%CI: 1.5-3.13), comorbidity (OR: 1.7, 95%CI: 1.22-2.37), patient's need for rheumatic care during HCI (OR: 3.2, 95%CI: 2.06-4.97) and adequate control of the rheumatic disease (OR: 0.64, 95%CI: 0.45-0.9) were independently associated to HCI. There were 160 patients (23.8%) with clinical deterioration and associated factors were disease duration, substantial disease activity previous HCI, patients need for rheumatic care and treatment discontinuation.

CONCLUSIONS

HCI during COVID-19 pandemic impacted course of rheumatic diseases and need to be considered in the bioethical analysis of virus containment measures.

Microscopic polyangiitis associated with coronavirus disease-2019 (COVID-19) infection in an elderly male

Background

Microscopic polyangiitis (MPA) is an antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) that affects predominantly small- sized vessels. A causal relationship between viral infections and vasculitis has been postulated.Aim of the workTo present the concomitant association of coronavirus disease 2019 (COVID-19) infection with MPA in an elderly Iranian male.

Case presentation

A 67 year old Iranian man with the history of COVID-19 infection and a positive polymerized chain reaction (PCR) test four weeks before admission to the neurology department with acute onset pain, numbness and progressive weakness in both hands grip, sudden left foot drop and paresthesia. Erythrocyte sedimentation rate (ESR) was 95 mm/hr, ferritin 912 ng/ml and C-reactive protein (CRP) positive, proteinuria 1.1 g/24 h and markedly elevated perinuclear (P-ANCA): 526 IU/ml. Diagnosis of MPA was held presenting with mononeuritis multiplex, glomerulonephritis followed by diffuse alveolar hemorrhage and infiltration of lymphocytes in muscle fibers and vessels wall in sural nerve biopsy. He was successfully treated by methylprednisolone (1 g/day for 3 days) followed by 1 mg/kg with gradual tapering along with cyclophosphamide (CYC) (2 mg/kg). Intravenous immunoglobulin (IVIG, 2 g/kg in four divided doses) started for the management of inflammatory mononeuritis multiplex with gradual improvement. During hospitalization, plasmapheresis was performed due to alveolar hemorrhage for 5 day. The patient returned home on day 32 and followed-up in the rheumatology clinic with improvement of muscle power and handgrip strength.

Conclusion

Vasculitis is potentially one of COVID-19's presenting symptoms and prompt diagnosis and treatment is crucial in improving outcome of patients.

A novel multi-omics-based highly accurate prediction of symptoms, comorbid conditions, and possible long-term complications of COVID-19

Comprehensive clinical pictures, comorbid conditions, and long-term complications of COVID-19 are still unknown. Recently, using a multi-omics-based strategy, we predicted potential drugs for COVID-19 with ∼70% accuracy. Herein, using a novel multi-omics-based bioinformatic approach and three ways of analysis, we identified the symptoms, comorbid conditions, and short-, mid-, and possible long-term complications of COVID-19 with >90% precision including 27 parent, 170 child, and 403 specific conditions. Among the specific conditions, 36 viral, 53 short-term, 62 short-mid-long-term, 194 mid-long-term, and 57 congenital conditions are identified. At a threshold "count of occurrence" of 4, we found that 83-100% (average 92.67%) of enriched conditions are associated with COVID-19. Except for dry cough and loss of taste, all the other COVID-19-associated mild and severe symptoms are enriched. CVDs, and pulmonary, metabolic, musculoskeletal, neuropsychiatric, kidney, liver, and immune system disorders are top comorbid conditions. Specific diseases like myocardial infarction, hypertension, COPD, lung injury, diabetes, cirrhosis, mood disorders, dementia, macular degeneration, chronic kidney disease, lupus, arthritis, etc. along with several other NCDs were found to be top candidates. Interestingly, many cancers and congenital disorders associated with COVID-19 severity are also identified. Arthritis, gliomas, diabetes, psychiatric disorders, and CVDs having a bidirectional relationship with COVID-19 are also identified as top conditions. Based on our accuracy (>90%), the long-term presence of SARS-CoV-2 RNA in human, and our "genetic remittance" assumption, we hypothesize that all the identified top-ranked conditions could be potential long-term consequences in COVID-19 survivors, warranting long-term observational studies.

Impact of COVID-19 pandemic on rheumatoid arthritis from a Multi-Centre patient-reported questionnaire survey: influence of gender, rural-urban gap and north-south gradient

During the coronavirus disease-2019 (COVID-19) pandemic there were several barriers to treatment access and medication adherence in rheumatoid arthritis (RA) patients. There is no information regarding the RA patient health status in Egypt during the COVID-19. Thus,the aim of this work was to study the impact of the pandemic on RA patients through a patient-reported questionnaire and to determine the influence of gender, geographic regions. This multi-centre study initiated by the Egyptian College of Rheumatology (ECR) was conducted on 1037 RA patients attending rheumatology clinics from 10 governorates. The questionnaire provided covered socio-demographic data, health/disease status, information/knowledge about COVID-19 and medical/family history of the infection. Patients mean age was 44.2 ± 12.3 years;855 females and 182 males; 539(52%) from rural and 497(48%) from urban areas. 41.8% reported a striking difficulty to obtain hydroxychloroquine during the pandemic. The majority (70%) considered maintaining a regular visit to the rheumatologist in addition to remote contact mainly by phone (44.4%) or via WhatsApp (33.1%), in particular among male and urban patients. Urban patients were more likely to be infected by COVID-19 (12.9% vs 6.2%; p < 0.0001) than rural. Northern cities had more patients with suspected COVID-19 (13.9% vs 6.1%; p < 0.0001); was significantly associated with more disease flares (30.8% vs 5.8%) with subsequent change in the RA treatment (20.9% vs 6.4%; p < 0.0001). Patients with RA faced remarkable difficulty to obtain their medications with subsequent change in their disease status. The challenges of the pandemic have hastened changes in the way we deliver health care.