COVID-19 and myositis - unique challenges for patients

Gender differences in patient experience in idiopathic inflammatory myopathies: Subanalysis from the COVAD dataset

OBJECTIVES

We aimed to investigate the gender-based differences in idiopathic inflammatory myopathies (IIMs), with a particular focus on patient-reported outcomes, utilizing the data obtained through the international COVID-19 vaccination in autoimmune disease e-survey.

METHODS

Patient-reported outcomes including fatigue, pain, and physical function were extracted from the COVID-19 vaccination in autoimmune disease database and compared between genders, adjusting for demographics and IIM subgroups by multivariable analysis. Inclusion body myositis (IBM) was analysed separately because of the substantial differences in outcomes.

RESULTS

A total of 1197 complete responses from patients with IIMs as of 31 August 2021 were analysed. Seventy percent were women. Women were younger (58 [48-68] vs. 69 [58-75] years old, median [interquartile range], P < .001) and were more likely to suffer from autoimmune multimorbidity, defined as three or more autoimmune diseases in an individual patient (11.4% vs. 2.8%, P < .001). In non-IBM IIMs, fatigue visual analogue scale scores were higher in women (5 [3-7] vs. 4 [2-6], median [interquartile range], P = .004), whereas no significant gender-based differences were noted in IBM. Multivariable analysis in non-IBM IIMs revealed that women, residence in high-income countries, overlap myositis, and autoimmune multimorbidity were independently associated with increased fatigue.

CONCLUSIONS

Women with IIMs suffer from autoimmune multimorbidity and experience increased fatigue compared to men.

Listening to patients, for the patients: The COVAD Study-Vision, organizational structure, and challenges

BACKGROUND

The pandemic presented unique challenges for individuals with autoimmune and rheumatic diseases (AIRDs) due to their underlying condition, the effects of immunosuppressive treatments, and increased vaccine hesitancy.

OBJECTIVES

The COVID-19 vaccination in autoimmune diseases (COVAD) study, a series of ongoing, patient self-reported surveys were conceived with the vision of being a unique tool to gather patient perspectives on AIRDs. It involved a multinational, multicenter collaborative effort amidst a global lockdown.

METHODS

Leveraging social media as a research tool, COVAD collected data using validated patient-reported outcomes (PROs). The study, comprising a core team, steering committee, and global collaborators, facilitated data collection and analysis. A pilot-tested, validated survey, featuring questions regarding COVID-19 infection, vaccination and outcomes, patient demographics, and PROs was circulated to patients with AIRDs and healthy controls (HCs).

DISCUSSION

We present the challenges encountered during this international collaborative project, including coordination, data management, funding constraints, language barriers, and authorship concerns, while highlighting the measures taken to address them.

CONCLUSION

Collaborative virtual models offer a dynamic new frontier in medical research and are vital to studying rare diseases. The COVAD study demonstrates the potential of online platforms for conducting large-scale, patient-focused research and underscores the importance of integrating patient perspective into clinical care. Care of patients is our central motivation, and it is essential to recognize their voices as equal stakeholders and valued partners in the study of the conditions that affect them.

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.

Flares in IIMs and the timeline following COVID-19 vaccination: a combined analysis of the COVAD-1 and -2 surveys

OBJECTIVES

Disease flares in the post-coronavirus disease 2019 (COVID-19) vaccination period represent a prominent concern, though risk factors are poorly understood. We studied these flares among patients with idiopathic inflammatory myopathies (IIMs) and other autoimmune rheumatic diseases (AIRDs).

METHODS

The COVAD-1 and -2 global surveys were circulated in early 2021 and 2022, respectively, and we captured demographics, comorbidities, AIRDs details, COVID-19 infection history and vaccination details. Flares of IIMs were defined as (a) patient self-reported, (b) immunosuppression (IS) denoted, (c) clinical sign directed and (d) with >7.9-point minimal clinically significant improvement difference worsening of Patient-Reported Outcomes Measurement Information System (PROMIS) PROMISPF10a score. Risk factors of flares were analysed using regression models.

RESULTS

Of 15 165 total respondents, 1278 IIMs (age 63 years, 70.3% female, 80.8% Caucasians) and 3453 AIRDs were included. Flares of IIM were seen in 9.6%, 12.7%, 8.7% and 19.6% patients by definitions (a) to (d), respectively, with a median time to flare of 71.5 (10.7-235) days, similar to AIRDs. Patients with active IIMs pre-vaccination (OR 1.2; 95% CI 1.03, 1.6, P = 0.025) were prone to flares, while those receiving rituximab (OR 0.3; 95% CI 0.1, 0.7, P = 0.010) and AZA (OR 0.3, 95% CI 0.1, 0.8, P = 0.016) were at lower risk. Female gender and comorbidities predisposed to flares requiring changes in IS. Asthma (OR 1.62; 95% CI 1.05, 2.50, P = 0.028) and higher pain visual analogue score (OR 1.19; 95% CI 1.11, 1.27, P < 0.001) were associated with disparity between self-reported and IS-denoted flares.

CONCLUSION

A diagnosis of IIMs confers an equal risk of flares in the post-COVID-19 vaccination period to AIRDs, with active disease, female gender and comorbidities conferring a higher risk. Disparity between patient- and physician-reported outcomes represents a future avenue for exploration.

Patients with dermatomyositis shared partially similar transcriptome signature with COVID-19 infection

Dermatomyositis (DM) is an autoimmune disease that primarily affects the skin and skeletal muscle. Virus infection and type I interferon-related signaling pathways play an important role in the pathogenesis of dermatomyositis. In this study, we found that the skin of patients with DM and the skin of patients with COVID-19 have similar transcriptional profiles, and identified key genes involved in dermatomyositis based on bioinformatics analysis. These hub-genes might be served as potential biomarkers for the early diagnosis and therapy of DM, including MX1, ISG15, IFIT3, IFIT1, RSAD2, IFIT2, IFI6, XAF1, IRF9, MX2.

Cost of illness in inclusion body myositis: results from a cross-sectional study in Germany

BACKGROUND

Inclusion body myositis (IBM) is the most frequent type of myositis in elder patients with a slow chronic progression and refractory to treatment. Previous cost of illness (COI) studies in IBM used claims data to estimate direct costs in the US. No evidence exists globally on both direct and indirect costs in IBM from a societal perspective. We conducted a survey in patients registered in the German IBM patient registry. Self-developed items were used to assess the utilized healthcare resources and estimate the cost. The German Self-Administered Comorbidity Questionnaire (SCQ-D), the sIBM Physical Functioning Assessment (sIFA) and patient-reported measures for satisfaction and improvements in healthcare were applied for an explorative analysis.

RESULTS

In total, 82 patients completed the survey. We estimated the mean total annual per capita COI of US$102,682 (95% CI US$82,763-US$123,090) in 2021. 92.7% of the total COI were direct costs. Medical costs were similar to nonmedical costs, with substantial costs for pharmacotherapy and informal care. Depending on the prevalence estimate, the total national COI per year were US$42.7 million-US$213.7 million. Significant differences in total COI were identified for the degree of disability, marital and employment status (p < 0.05).

CONCLUSIONS

We identified remarkable and heterogenous cost in IBM. As informal care costs represented the most relevant cost driver, caregiver burden is a major factor in the patient journey. For the first time, comprehensive economic potentials were identified as a basis to improve the actual care situations and prioritizing future activities for research, pharmaceutical and digital product development as well as health politics.

Vaccine hesitancy decreases in rheumatic diseases, long-term concerns remain in myositis: a comparative analysis of the COVAD surveys

OBJECTIVE

COVID-19 vaccines have a favorable safety profile in patients with autoimmune rheumatic diseases (AIRDs) such as idiopathic inflammatory myopathies (IIMs); however, hesitancy continues to persist among these patients. Therefore, we studied the prevalence, predictors and reasons for hesitancy in patients with IIMs, other AIRDs, non-rheumatic autoimmune diseases (nrAIDs) and healthy controls (HCs), using data from the two international COVID-19 Vaccination in Autoimmune Diseases (COVAD) e-surveys.

METHODS

The first and second COVAD patient self-reported e-surveys were circulated from March to December 2021, and February to June 2022 (ongoing). We collected data on demographics, comorbidities, COVID-19 infection and vaccination history, reasons for hesitancy, and patient reported outcomes. Predictors of hesitancy were analysed using regression models in different groups.

RESULTS

We analysed data from 18 882 (COVAD-1) and 7666 (COVAD-2) respondents. Reassuringly, hesitancy decreased from 2021 (16.5%) to 2022 (5.1%) (OR: 0.26; 95% CI: 0.24, 0.30, P < 0.001). However, concerns/fear over long-term safety had increased (OR: 3.6; 95% CI: 2.9, 4.6, P < 0.01). We noted with concern greater skepticism over vaccine science among patients with IIMs than AIRDs (OR: 1.8; 95% CI: 1.08, 3.2, P = 0.023) and HCs (OR: 4; 95% CI: 1.9, 8.1, P < 0.001), as well as more long-term safety concerns/fear (IIMs vs AIRDs - OR: 1.9; 95% CI: 1.2, 2.9, P = 0.001; IIMs vs HCs - OR: 5.4 95% CI: 3, 9.6, P < 0.001). Caucasians [OR 4.2 (1.7-10.3)] were likely to be more hesitant, while those with better PROMIS physical health score were less hesitant [OR 0.9 (0.8-0.97)].

CONCLUSION

Vaccine hesitancy has decreased from 2021 to 2022, long-term safety concerns remain among patients with IIMs, particularly in Caucasians and those with poor physical function.

Long-term safety of COVID vaccination in individuals with idiopathic inflammatory myopathies: results from the COVAD study

Limited evidence on long-term COVID-19 vaccine safety in patients with idiopathic inflammatory myopathies (IIMs) continues to contribute to vaccine hesitancy. We studied delayed-onset vaccine adverse events (AEs) in patients with IIMs, other systemic autoimmune and inflammatory disorders (SAIDs), and healthy controls (HCs), using data from the second COVID-19 Vaccination in Autoimmune Diseases (COVAD) study. A validated self-reporting e-survey was circulated by the COVAD study group (157 collaborators, 106 countries) from Feb-June 2022. We collected data on demographics, comorbidities, IIM/SAID details, COVID-19 history, and vaccination details. Delayed-onset (> 7 day) AEs were analyzed using regression models. A total of 15165 respondents undertook the survey, of whom 8759 responses from vaccinated individuals [median age 46 (35-58) years, 74.4% females, 45.4% Caucasians] were analyzed. Of these, 1390 (15.9%) had IIMs, 50.6% other SAIDs, and 33.5% HCs. Among IIMs, 16.3% and 10.2% patients reported minor and major AEs, respectively, and 0.72% (n = 10) required hospitalization. Notably patients with IIMs experienced fewer minor AEs than other SAIDs, though rashes were expectedly more than HCs [OR 4.0; 95% CI 2.2-7.0, p < 0.001]. IIM patients with active disease, overlap myositis, autoimmune comorbidities, and ChadOx1 nCOV-19 (Oxford/AstraZeneca) recipients reported AEs more often, while those with inclusion body myositis, and BNT162b2 (Pfizer) recipients reported fewer AEs. Vaccination is reassuringly safe in individuals with IIMs, with AEs, hospitalizations comparable to SAIDs, and largely limited to those with autoimmune multimorbidity and active disease. These observations may inform guidelines to identify high-risk patients warranting close monitoring in the post-vaccination period.

SOCIAL MEDIA IN SCIENCE

Day by day, social media are entering our lives changing our every-day life and habits. This could not leave science unaffected. Over the last years, a lot of scientists have started using social media, exchanging ideas and sharing knowledge. Scientific journals have also followed being active participators in the social media world. In this opinion article we provide some arguments about the positive role of social media in the life of a scientist, highlighting at the same time the caveats that are encountered.  

COVID-19 vaccination-related adverse events among autoimmune disease patients: results from the COVAD study

OBJECTIVES

COVID-19 vaccines have been proven to be safe in the healthy population. However, gaps remain in the evidence of their safety in patients with systemic autoimmune and inflammatory disorders (SAIDs). COVID-19 vaccination-related adverse events (AEs) in patients with SAIDs and healthy controls (HC) seven days post-vaccination were assessed in the COVAD study, a patient self-reported cross-sectional survey.

METHODS

The survey was circulated in early 2021 by >110 collaborators (94 countries) to collect SAID details, COVID-19 vaccination details and 7-day vaccine AEs, irrespective of respondent vaccination status. Analysis was performed based on data distribution and variable type.

RESULTS

Ten thousand nine hundred respondents [median (interquartile range) age 42 (30-55) years, 74% females and 45% Caucasians] were analysed; 5867 patients (54%) with SAIDs were compared with 5033 HCs. Seventy-nine percent had minor and only 3% had major vaccine AEs requiring urgent medical attention (but not hospital admission) overall. Headache [SAIDs = 26%, HCs = 24%; odds ratio (OR) = 1.1 (95% CI: 1.03, 1.3); P = 0.014], abdominal pain [SAIDs = 2.6%, HCs = 1.4%; OR = 1.5 (95% CI: 1.1, 2.3); P = 0.011], and dizziness [SAIDs = 6%, HCs = 4%; OR = 1.3 (95% CI: 1.07, 1.6); P = 0.011], were slightly more frequent in SAIDs. Overall, major AEs [SAIDs = 4%, HCs = 2%; OR = 1.9 (95% CI: 1.6, 2.2); P < 0.001] and, specifically, throat closure [SAIDs = 0.5%, HCs = 0.3%; OR = 5.7 (95% CI: 2.9, 11); P = 0.010] were more frequent in SAIDs though absolute risk was small (0-4%). Major AEs and hospitalizations (<2%) were comparable across vaccine types in SAIDs.

CONCLUSION

Vaccination against COVID-19 is safe in SAID patients. SAIDs were at a higher risk of major AEs than HCs, though absolute risk was small. There are small differences in minor AEs between vaccine types in SAID patients.

Inflammatory Myopathies

PURPOSE OF REVIEW

This article outlines the salient clinical, serologic, electrophysiologic, imaging, and histopathologic findings and treatment options for the idiopathic inflammatory myopathies, including those related to immune checkpoint inhibitors and SARS-CoV-2.

RECENT FINDINGS

The classification of idiopathic inflammatory myopathies has improved with the integration of myositis-specific antibodies and histopathologic findings. Characteristic features of immune checkpoint inhibitor-related myositis have been identified, allowing early recognition and treatment of the syndrome. The COVID-19 pandemic has had a profound impact on the care of patients with idiopathic inflammatory myopathies, and several mechanisms of virus-related muscle injury have been proposed.

SUMMARY

A comprehensive evaluation including clinical examination, EMG, imaging, antibody testing, muscle biopsy, and cancer screening, when appropriate, can lead to an earlier accurate diagnosis and an individualized treatment approach for patients with idiopathic inflammatory myopathies.

Dermatomyositis Flare After a COVID-19 Infection Successfully Treated with Rituximab: A Case Report and Literature Review

INTRODUCTION

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, there has been a sudden surge in the incidence of several immune-mediated diseases, including dermatomyositis. The reported cases of COVID-19-related dermatomyositis are heterogeneous in their clinical presentation and implemented therapies.

CASE STUDY

We report a 23-year-old female patient diagnosed with a 3-year history of dermatomyositis. She has been well-controlled on maintenance therapy. However, 6 weeks after a mild COVID-19 infection, she developed a dermatomyositis flare. She improved only after aggressive treatment with pulse steroids, intravenous immunoglobulin, and rituximab.

CONCLUSION

Exacerbation of dermatomyositis can be encountered following a COVID-19 infection, even if the infection is mild. Aggressive therapy should be considered in such cases. The prognosis, however, is generally favorable.

Assessment of risk factors in post- COVID-19 patients and its associated musculoskeletal manifestations: A cross-sectional study in India

INTRODUCTION

Musculoskeletal manifestations of COVID-19, post COVID-19, and post COVID-19 vaccination include arthralgia, myalgia, new-onset backache, fatigue, inflammatory arthritis either symmetrical or polyarticular, reactive arthritis, osteoporosis, osteonecrosis of the femoral head, neuropathies, myositis, and myopathies. Almost 15% and 44% of post-COVID-19 patients reported arthralgia and myalgia. We aim to analyze the musculoskeletal manifestations of COVID-19 infection and the factors determining their severity.

METHODOLOGY

This is a retrospective multicentric cross-sectional study conducted from all the four regions (northern, southern, eastern, and western regions) in India. The recruitment period was from June 1st, 2021, to September 30th, 2021. All patients with COVID-19 positivity in the past were classified into three groups (mild, moderate, and severe). The primary outcome is to find the correlation of musculoskeletal symptoms with disease positivity, severity, and demographic variables. We focused at clinical characteristics and symptoms at the time of admission, as well as comorbidities, laboratory findings, immunological findings, treatments, and outcomes.

RESULTS

The study was conducted among 2334 subjects across all the regions of India. Out of which 719 were COVID-19 positive individuals. Non-vaccinated were about 62.6% compared to 37.4% vaccinated among COVID-19 positive individuals. The total average musculoskeletal scores calculated were about 15.94 ± 54.86. MSK scores were significantly higher (p < 0.001) among males, uneducated, those with co-morbidities, and non-vaccinated individuals. Multivariate regression analysis showed a 1.63 times higher risk of having COVID-19 infection among smokers, those who don't exercise regularly are 1.25 times at risk of having COVID-19 infection. Similarly, those who have comorbidities are 1.93 times at risk of having COVID-19 infection. Non-vaccinated individuals were 2.33 times at risk of having COVID-19 infection.

CONCLUSION

Factors such as male sex, non-vaccination, and associated co-morbidities increased the risk of developing severe MSK manifestations upon infection with COVID-19 and needs extended monitoring to control the morbidity due to the same.

Impaired physical function in patients with idiopathic inflammatory myopathies: results from the multicentre COVAD patient-reported e-survey

OBJECTIVES

The assessment of physical function is fundamental in the management of patients with idiopathic inflammatory myopathies (IIMs). We aimed to investigate the physical function of patients with IIMs compared with those with non-IIM autoimmune rheumatic diseases (AIRDs) utilizing Patient-Reported Outcome Measurement Information System (PROMIS) Physical Function (PF) data obtained in the COVAD study, an international self-reported e-survey assessing the safety of COVID-19 vaccines in AIRDs.

METHODS

Demographics, AIRD diagnosis, disease activity, and PROMIS PF short form-10a data were extracted from the COVAD database. PROMIS PF-10a scores were compared between disease categories and stratified by disease activity. Factors affecting PROMIS PF-10a scores other than disease activity were identified by multivariable regression analysis in patients with inactive disease.

RESULTS

A total of 1057 IIM patients, 3635 non-IIM AIRD patients and 3981 healthy controls (HCs) responded to the COVAD e-survey from April to August 2021. Using a binomial regression model, the predicted mean of PROMIS PF-10a scores was significantly lower in IIM patients compared with non-IIM AIRD patients or HCs [36.3 (95% CI 35.5, 37.1) vs 41.3 (95% CI 40.2, 42.5) vs 46.2 (95% CI 45.8, 46.6), P < 0.001], irrespective of disease activity. The independent factors for lower PROMIS PF-10a scores in patients with inactive disease were older age, female, longer disease duration, and a diagnosis of inclusion body myositis or polymyositis.

CONCLUSION

Physical function is significantly impaired in IIMs compared with non-IIM AIRDs or HCs, even in patients with inactive disease. Our study highlights a critical need for better strategies to minimize functional disability in patients with IIMs.

Harnessing the benefits of yoga for myositis, muscle dystrophies, and other musculoskeletal disorders

The recent global increase in popularity of home-based yoga, an ancient Indian technique practiced for thousands of years, has translated into its use as a complementary therapy for a multitude of ailments. This review aims to examine the published literature regarding the effects of yoga therapy on systemic chronic diseases; in particular on the inflammatory myopathies (IMs) and other muscle disorders.

Despite the fact that the evidence base for yoga in inflammatory myositis is in its infancy, collateral results in other disorders such as muscular dystrophies are promising. A beneficial effect of yoga in chronic pain has been shown alongside an improvement in motor function and muscle strength. Patients with Duchenne muscular dystrophy with respiratory involvement may find improvement in lung function. Elderly patients may experience reduction in falls secondary to an improvement in balance while practicing long-term yoga therapy.

Further benefits are improving disorders of mental health such as depression and anxiety. A reported improvement in overall quality of life further suggests its efficacy in reducing morbidity in patients with chronic diseases, who often suffer co-existent psychological comorbidities.

Mechanic's Hand Heralding Relapse in an Indian Adolescent with Anti-MDA5 Positive Juvenile Dermatomyositis

Anti-MDA5 antibodies characterise a distinct phenotype of dermatomyositis in adults as well as children, with ethnic disparity in clinical presentation and severity. They often present as a diagnostic conundrum with rash, ulceration, and polyarthritis, but minimal muscle disease. Mechanic's hands are typically associated with anti-synthetase syndrome, but their presence in anti-MDA5 antibody positive patients, although reported, is not well known. We present the case of a boy in whom mechanic's hand heralded a relapse of juvenile dermatomyositis which was suspected based on remotely assessed patient-reported outcome measures on teleconsultation. This report suggests that mechanic's hands should also prompt testing for myositis antibodies including anti-MDA5 in Indian children with JDM. Diligent awareness of the condition, and timely use of patient reported outcome measures of muscle power and skin assessment may guide management while delivering remote care in challenging situations such as a global pandemic.

Acute neuromuscular syndromes with respiratory failure during COVID-19 pandemic: where we stand and challenges ahead

Coronavirus disease 2019 (COVID-19), a disease caused by the novel betacoronavirus SARS-COV-2, has become a global pandemic threat. SARS- COV-2 is structurally similar to SARS-COV, and both bind to the angiotensin-converting enzyme 2 (ACE2) receptor to enter human cells. While patients typically present with fever, shortness of breath, sore throat, and cough, in some cases neurologic manifestations occur due to both direct and indirect involvement of the nervous system. Case reports include anosmia, ageusia, central respiratory failure, stroke, acute necrotizing hemorrhagic encephalopathy, toxic-metabolic encephalopathy, headache, myalgia, myelitis, ataxia, and various neuropsychiatric manifestations. Some patients with COVID-19 may present with concurrent acute neuromuscular syndromes such as myasthenic crisis (MC), Guillain–Barré syndrome (GBS) and idiopathic inflammatory myopathies (IIM); these conditions coupled with respiratory failure could trigger a life-threatening condition. Here, we review the current state of knowledge on acute neuromuscular syndromes with respiratory failure related to COVID-19 infection in an attempt to clarify and to manage the muscle dysfunction overlapping SARS-COV-2 infection.

Case Report: Lower Limb Muscle Weakness in a Child With Kawasaki Disease

Kawasaki disease (KD) is a systemic vasculitis that may impact multiple organ systems in children. Myositis is an unusual presentation of KD that presents with muscle weakness. To date, a few pediatric patients with KD and myositis have been reported. Diffuse muscle weakness involving the 4 limbs was the most common presentation in these children. However, isolated lower limb involvement was rarely reported before. Here, we report lower limb muscle weakness in an 18-month-old child with KD. He presented with fever, rash, conjunctival injection, peeling over fingers and toes, and progressive muscle weakness of the lower limbs. Muscle enzymes were normal, but electromyography indicated myositis. The symptom of fever was relieved quickly by intravenous immunoglobulin and aspirin, which were ineffective for myositis. However, lower limb muscle weakness fully recovered 5 days after prednisolone treatment. This rare case might add value to the growing literature exploring the association of KD with myositis.

COVID-19 vaccination in autoimmune disease (COVAD) survey protocol

The coronavirus disease-2019 (COVID-19) pandemic continues to be a cause of unprecedented global morbidity and mortality. Whilst COVID-19 vaccination has emerged as the only tangible solution to reducing poor clinical outcomes, vaccine hesitancy continues to be an obstacle to achieving high levels of vaccine uptake. This represents particular risk to patients with autoimmune diseases, a group already at increased risk of hospitalization and poor clinical outcomes related to COVID-19 infection. Whilst there is a paucity of long-term safety and efficacy data of COVID-19 vaccination in patients with autoimmune diseases, the current evidence strongly suggests that the benefits of vaccination outweigh the risks of adverse effects and disease flares. Herein, we report the protocol of the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study, an ongoing international collaborative study involving 29 countries and over 110 investigators.

Validation of two simple patient-centered outcome measures for virtual monitoring of patients with idiopathic inflammatory myositis

BACKGROUND

Telemedicine has changed the landscape of patient care with wider use of patient-centered outcome measures (PCOMs). We evaluated two novel task-based PCOMs namely ten times arm lift (AL) test and two-minute walk distance (2MWD) in idiopathic myositis (IIM).

METHODS

This was a cross-sectional observational study with the enrolment of adult IIM (ACR/EULAR criteria) patients with active/inactive disease. Active disease was defined as any two of increase in immunosuppression within 3 months, elevated muscle enzymes, physician VAS ≥ 2, worsened cutaneous disease, or fall in MMT8 < 76. Standard myositis core set measures (CSMs) were evaluated and test-retest validity [Cronbach's alfa (CA)], construct validity (Pearson's correlation), and discriminant validity (between active/inactive IIM) were assessed. The results were further validated in a separate tele-rheumatology cohort.

RESULTS

Among 22 IIM patients (68%-female) of age 30.5(19-62) years, AL and 2MWD showed excellent test-retest reliability (CA-0.987, 0.99). AL exhibited moderate-strong correlation with all CSMs except CK levels and MDI. In contrast, 2MWD values were highly variable without CSM correlation. A higher AL time discriminated active and inactive myositis (16.6 vs 11 s, p = 0.006) with an AUC of 0.882 (p = 0.006). AL > 12.8 s had 94% negative predictive value (NPV) for active muscle disease. In the validation cohort (47 patient visits among 26 patients), AL significantly differentiated between active vs. inactive disease with an NPV of 95%.

CONCLUSIONS

AL test exhibits pilot evidence of construct and discriminant validity in patients with IIM requiring further evaluation. 2MWD was not a good test for outcome evaluation of IIM patients. Key Points • Novel task-based patient-centered outcome measures were evaluated for remote monitoring of muscle strength in IIM. • Ten times arm lift (AL) test showed strong test-retest reliability as well as provide pilot evidence of construct and discriminant validity in patients with IIM unlike 2-min walk distance. • This provides preliminary evidence to further evaluate the role of AL as patient-centered outcome measure in patients with IIM for virtual clinical trials.

Systemic autoimmune myopathies: A prospective phase 4 controlled trial of an inactivated virus vaccine against SARS-CoV-2

Objectives

To evaluate immunogenicity and safety of an inactivated SARS-CoV-2 vaccine in systemic autoimmune myopathies (SAMs) and the possible influence of baseline disease parameters, comorbidities and therapy on immune response.

Methods

This prospective controlled study included 53 patients with SAMs and 106 non-immunocompromised control group (CTRL). All participants received two doses of the Sinovac-CoronaVac vaccine (28-day interval). Immunogenicity was assessed by anti-SARS-CoV-2 S1/S2 IgG seroconversion (SC), anti-S1/S2 IgG geometric mean titre (GMT), factor increase GMT (FI-GMT), neutralizing antibodies (NAb) positivity, and median neutralizing activity after each vaccine dose (D0 and D28) and six weeks after the second dose (D69). Participants with pre-vaccination positive IgG serology and/or NAb and those with RT-PCR confirmed COVID-19 during the protocol were excluded from immunogenicity analysis.

Results

Patients and CTRL had comparable sex (P>0.99) and age (P=0.90). Immunogenicity of 37 patients and 79 CTRL-naïve participants revealed at D69, a moderate but significantly lower SC (64.9% vs 91.1%, P<0.001), GMT [7.9 (95%CI 4.7–13.2) vs 24.7 (95%CI 30.0–30.5) UA/ml, P<0.001] and frequency of NAb (51.4% vs 77.2%, P<0.001) in SAMs compared with CTRL. Median neutralizing activity was comparable in both groups [57.2% (interquartile range (IQR) 43.4–83.4) vs 63.0% (IQR 40.3–80.7), P=0.808]. Immunosuppressives were less frequently used among NAb+ patients vs NAb- patients (73.7% vs 100%, P=0.046). Type of SAMs, disease status, other drugs or comorbidities did not influence immunogenicity. Vaccine-related adverse events were mild with similar frequencies in patients and CTRL (P>0.05).

Conclusion

Sinovac-CoronaVac is safe and has a moderate short-term immunogenicity in SAMs, but reduced compared with CTRL. We further identified that immunosuppression is associated with diminished NAb positivity.

Trial registration

COVID-19 CoronaVac in Patients With Autoimmune Rheumatic Diseases and HIV/AIDS (CoronavRheum), http://clinicaltrials.gov/ct2/show/NCT04754698

Short term outcomes of COVID-19 in lupus: Propensity score matched analysis from a nationwide multi-centric research network

Objectives

To determine the severity and outcome of COVID-19 among individuals with lupus as compared to controls. The secondary objective was to identify the risk association of sex, race, presence of nephritis, and use of various immunomodulators with COVID-19 outcomes.

Methods

Retrospective data of individuals with lupus with and without COVID-19 between January 2020 to May 2021 was retrieved from the TriNetX. A one-to-one matched COVID-19 positive control was selected using propensity score(PS) matching. We assessed several outcomes, including all-cause mortality, hospitalisation, intensive care unit (ICU) admission, mechanical ventilation, severe COVID, acute kidney injury (AKI), Haemodialysis, acute respiratory distress syndrome (ARDS), ischemic stroke, venous thromboembolism (VTE) and sepsis were assessed.

Results

We identified 2140 SLE patients with COVID-19, 29,853 SLE without COVID-19 and 732,291controls. Mortality within 30 days of COVID-19 diagnosis was comparable among SLE and controls [RR-1.26; 95%CI-0.85,1.8]. SLE with COVID-19 had a higher risk of hospitalisation [RR-1.28; 95% CI 1.14–1.44], ICU admission [RR-1.35; 95% CI 1.01–1.83], mechanical ventilation [RR- 1.58 95% CI 1.07–2.33], stroke [RR-2.18; 95% CI 1.32,3.60], VTE [RR-2.22; 95% CI 1.57–03.12] and sepsis [RR-1.37; 95% CI 1.06–1.78].Individuals with SLE who contracted COVID-19 had higher mortality, hospitalisation, ICU admission, mechanical ventilation, AKI, VTE and sepsis (p < 0.001) compared to SLE without COVID-19. Males with SLE had a higher risk of AKI [RR-2.05; 95% CI 1.27–3.31] than females. Lupus nephritis was associated with higher risk of hospitalisation [RR-1.36; 95% CI 1.05–1.76], AKI [RR-2.32; 95% CI 1.50–3.59] and sepsis [RR-2.07; 95% CI-1.12–3.83].

Conclusion

The mortality of individuals with SLE due to COVID-19 is comparable to the general population but with higher risks of hospitalisation, ICU admission, mechanical ventilation, stroke, VTE and sepsis. The presence of nephritis increases the risk of AKI, thus probably increasing hospitalisation and sepsis

Systemic flare and cutaneous ulceration following cytomegalovirus infection in a patient with anti-melanoma differentiation-associated protein 5 (MDA5) associated myositis: Diagnostic challenge during the time of coronavirus disease (COVID-19) pandemic

Background

Anti-melanoma differentiation-associated protein 5 (MDA5) associated idiopathic inflammatory myopathy (IIM) often manifests with minimal muscle weakness and rapidly progressive interstitial lung disease (RP-ILD) with a poor prognosis. The clinical presentation may be varied in different ethnic groups. The ongoing coronavirus disease (COVID-19) pandemic has made management even more challenging as certain manifestations may be difficult to diagnose remotely.

Aim of the work

To throw light on the rare association of CMV infection in established anti-MDA5 myositis with severe consequences. Similar cases were presented and compared.

Case report

A 42-year-old lady presented with heliotrope rash, periorbital edema, ulcerated Gottron's papules, proximal muscle weakness and intermittent fever of six-month duration. Anti-MDA5 antibodies were positive. Active disease, including myocarditis and RP-ILD, were challenging to diagnose on teleconsultation. Upon initiating tofacitinib, cytomegalovirus (CMV) polymerized chain reaction (PCR) came positive. Ganciclovir was started with the possibility of viral activation being the potential driving force for interferon pathway activation and dermatomyositis (DM) flare, but the patient succumbed to the illness.

Conclusion

Viral triggers are known to induce autoimmune disease in the genetically predisposed. However, CMV infection in established anti-MDA5 myositis is uncommon and further association with myocarditis is a rare occurrence. Ulcerated Gottron's and periorbital oedema may carry a sinister connotation in Indians with anti-MDA5 DM, with worse manifestations such as myocarditis- which albeit rare, can be fatal.

COVID-19 and Myositis: What We Know So Far

PURPOSE

Myositis as a rare manifestation of COVID-19 is only recently being reported. This review examines the current literature on COVID-19-induced myositis focusing on etiopathogenesis, clinical presentations, diagnostic practices, and therapeutic challenges with immunosuppression, and the difficulties experienced by rheumatologists in established myositis in the COVID-19 era.

RECENT FINDINGS

COVID-19 is associated with a viral myositis attributable to direct myocyte invasion or induction of autoimmunity. COVID-19-induced myositis may be varied in presentation, from typical dermatomyositis to rhabdomyolysis, and a paraspinal affliction with back pain. It may or may not present with acute exponential elevations of enzyme markers such as creatine kinase (CK). Virus-mediated muscle inflammation is attributed to ACE2 (angiotensin-converting enzyme) receptor-mediated direct entry and affliction of muscle fibers, leading on to innate and adaptive immune activation. A greater recognition of the stark similarity between anti-MDA5-positive myositis with COVID-19 has thrown researchers into the alley of exploration - finding common etiopathogenic basis as well as therapeutic strategies. For patients with established myositis, chronic care was disrupted during the pandemic with several logistic challenges and treatment dilemmas leading to high flare rates. Teleconsultation bridged the gap while ushering in an era of patient-led care with the digital transition to tools of remote disease assessment. COVID-19 has brought along greater insight into unique manifestations of COVID-19-related myositis, ranging from direct virus-induced muscle disease to triggered autoimmunity and other etiopathogenic links to explore. A remarkable shift in the means of delivering chronic care has led patients and caregivers worldwide to embrace a virtual shift with teleconsultation and opened doorways to a new era of patient-led care.

Modern Health Journalism and the Impact of Social Media

Scholarly journals are hubs of hypotheses, evidence-based data, and practice recommendations that shape health research and practice worldwide. The advancement of science and information technologies has made online accessibility a basic requirement, paving the way for the advent of open access publishing, and more recently, to web-based health journalism. Especially in the time of the current pandemic, health professionals have turned to the internet, and primarily to social media, as a source of rapid information transfer and international communication. Hence, the current pandemic has ushered an era of digital transformation of science, and we attempt to understand and assess the impact of this digitization on modern health journalism.

Increased risk of mental health disorders in patients with RA during the COVID-19 pandemic: a possible surge and solutions

Depression is a common co-morbidity among rheumatoid arthritis (RA) patients, which may translate into difficulty performing activities of daily living. COVID-19 is an unprecedented disaster that has disrupted lives worldwide and led to a rise in the incidence of mental health disorders. Given the widespread economic devastation due to COVID-19, many RA patients, already susceptible to mental illness, maybe at an increased risk of inaccessibility to medical care, accentuated stress, and consequent worsening of existent mental health disorders, or the onset of new mental health disorders such as anxiety, post-traumatic stress disorder, or depression. The objective of this review is to assess if there is an increased risk of mental health disorders in patients with RA during the COVID-19 pandemic. Telemedicine has bridged the transition to remote chronic care in the pandemic period, though certain accessibility and technological challenges are to be addressed. Decreased access to care amid lockdowns and a proposed triggering of disease activity in patients with autoimmune disorders may potentially herald a massive spike in incidence or flares of patients diagnosed with RA in the coming months. Such a deluge of cases may be potentially devastating to an overburdened healthcare system. Rheumatologists may need to prepare for this eventuality and explore techniques to provide adequate care during these challenging times. The authors found that there is a significant association between the adverse impact on the mental health of RA patients and the COVID-19 pandemic. However, more research is needed to highlight individual risk factors.

Understanding and managing anti-MDA 5 dermatomyositis, including potential COVID-19 mimicry

Anti-Melanoma Differentiation-Associated gene 5 (MDA-5) Dermatomyositis (MDA5, DM) is a recently identified subtype of myositis characteristically associated with Rapidly Progressive Interstitial Lung Disease (RP-ILD) and unique cutaneous features. We reviewed PubMed, SCOPUS and Web of Science databases and selected 87 relevant articles after screening 1485 search results, aiming to gain a better understanding of the pathophysiology, clinical features, diagnosis, and treatment approaches of anti-MDA-5 DM described in the literature. The etiopathogenesis is speculatively linked to an unidentified viral trigger on the background of genetic predisposition culminating in an acquired type I interferonopathy. The clinical phenotype is highly varied in different ethnicities, with new clinical features having been recently described, expanding the spectrum of cases that should raise the suspicion of anti-MDA-5 DM. Unfortunately, the diagnosis is frequently missed despite excessive mortality, calling for wider awareness of suspect symptoms. RP ILD is the major determinant of survival, treatment being largely based on observational studies with recent insights into aggressive combined immunosuppression at the outset.

An Integrated Guide for Designing Video Abstracts Using Freeware and Their Emerging Role in Academic Research Advancement

Video abstracts (VAs) are a motion picture equivalent of written abstracts. With greater use of social media platforms for post publication promotions of research articles, VAs have gained increasing popularity among researchers in recent years. Widespread lockdowns and social distancing protocols in the pandemic period furthered the use of VAs as a tool for efficient learning. Moreover, these may be the preferred medium for communicating certain types of information, such as diagnostic or therapeutic procedures, qualitative research, perspectives, and techniques. In this article, the authors discuss the role of VAs in the advancement of academic research, plausible designs, freeware for making videos, and specific considerations for crafting good VAs.

Social Media for Scholarly Communication in Central Asia and Its Neighbouring Countries

The current digital era has led to a surge in the use of Social Media in academia. Worldwide connectivity has brought to the fore a scarce participation of Central Asia and adjoining regions in scientific discussions. Global perspectives in science may not be recorded due to such communication disparities. An equal representation of all ethnic groups is essential to have a rounded picture of the topic at hand. The extent of use of social media platforms in various regions is determined by social, economic, religious, political, cultural and ethnic factors, which may limit participation. The paper aims to examine the use of social media by academicians in the Central Asian countries, China and Mongolia. It also focusses on the linguistic skills of the Central Asian, Chinese and Mongolian population and their eagerness to be involved in global discussions. Understanding the factors limiting participation from specific regions is the first step in this direction.

Reporting Survey Based Studies - a Primer for Authors

The coronavirus disease 2019 (COVID-19) pandemic has led to a massive rise in survey-based research. The paucity of perspicuous guidelines for conducting surveys may pose a challenge to the conduct of ethical, valid and meticulous research. The aim of this paper is to guide authors aiming to publish in scholarly journals regarding the methods and means to carry out surveys for valid outcomes. The paper outlines the various aspects, from planning, execution and dissemination of surveys followed by the data analysis and choosing target journals. While providing a comprehensive understanding of the scenarios most conducive to carrying out a survey, the role of ethical approval, survey validation and pilot testing, this brief delves deeper into the survey designs, methods of dissemination, the ways to secure and maintain data anonymity, the various analytical approaches, the reporting techniques and the process of choosing the appropriate journal. Further, the authors analyze retracted survey-based studies and the reasons for the same. This review article intends to guide authors to improve the quality of survey-based research by describing the essential tools and means to do the same with the hope to improve the utility of such studies.

Teleconsultation experience with the idiopathic inflammatory myopathies: a prospective observational cohort study during the COVID-19 pandemic

Teleconsultation has assumed a central role in the management of chronic and disabling rheumatic diseases, such as the idiopathic inflammatory myopathies (IIM), during COVID-19. However, the feasibility, challenges encountered, and outcomes remain largely unexplored. Here, we describe our teleconsultation experience in a prospectively followed cohort of adult and juvenile IIM. 250 IIM enrolled into the MyoCite cohort (2017-ongoing) were offered the option of audio/visual teleconsultation using WhatsApp during the nationwide lockdown. Clinical outcomes (major/minor relapse) and prescription changes were compared between IIM subsets. Socio-demographic and clinico-serological characteristics of those who sought teleconsultation were compared with those who did not. 151 teleconsultations were sought over a 93 day period by 71 (52.2%) of 136 IIM (median age 38 years, F:M 4.5:1). Nearly one-third (38%) consulted on an emergency basis, with voice consultations being the primary medium of communication. Over a quarter (26.8%) reported relapse (15.5% minor, 11.3% major), these being more common in JDM [71.4%, OR 8.9 (1.5-51)] as compared with adult IIM, but similar across various antibody-based IIM subtypes. Patients who relapsed required more consultations [2(2-3) vs 1(1-2), p 0.009]. The demographic and socioeconomic profile of the patients seeking consultation (n = 71) was not different from those who did not (n = 65). Voice-based teleconsultations may be useful to diagnose and manage relapses in IIM during the pandemic. Patient education for meticulous and timely reporting may be improve care, and larger multicentre studies may identify subsets of IIM that require greater care and early tele-triage for effective management of the condition.