Baseline peripheral blood neutrophil-to-lymphocyte ratio could predict survival in patients with adult polymyositis and dermatomyositis: A retrospective observational study

The Clinical Value of the Neutrophil-to-Lymphocyte Ratio, the C-Reactive Protein-to-Albumin Ratio, the Systemic Inflammatory Index, and the Systemic Inflammatory Response Index in Patients with the Anti-Synthetase Syndrome

Objective

There are no studies examining the role of the neutrophil-to-lymphocyte ratio (NLR), the C-reactive protein-to-albumin ratio (CAR), the systemic inflammatory index (SII), and the systemic inflammatory response index (SIRI) in anti-synthetase syndrome (ASS). We aim to compare NLR, CAR, SII, and SIRI in ASS and dermatomyositis/polymyositis (DM/PM), as well as to examine potential correlations between NLR, CAR, SII, and SIRI and clinical features and laboratory parameters in ASS.

Methods

Retrospective collection of data from 111 patients with ASS and 175 patients with DM/PM. A Spearman rank correlation analysis was utilized to analyze the correlation between NLR, CAR, SII, and SIRI and inflammatory indexes. Receiver operating characteristic (ROC) curves were used to assess the diagnostic value. Univariate logistic regression analysis was performed to assess risk factors for interstitial lung disease (ILD).

Results

Compared with DM/PM, NLR, CAR, SII, and SIRI were significantly greater in ASS patients (p < 0.05). NLR, CAR, SII, and SIRI were correlated with albumin, lactic dehydrogenase (LDH), C-reactive protein (CRP), ferritin, white blood cell (WBC), platelets, and myositis disease activity assessment visual analog scales (MYOACT) score (p < 0.05). The ROC curves analysis showed that NLR, SII, and SIRI were all highly predictive of the occurrence of ASS. Comparisons based on clinical characteristics showed elevated levels of NLR, CAR, SII, and SIRI in ASS patients with ILD, fever, and infection (p < 0.05). Univariate logistic regression analysis revealed that NLR, CAR, and SII were significant risk factors for ASS-ILD (p < 0.05).

Conclusion

The levels of NLR, CAR, SII, and SIRI were higher in ASS than in DM/PM and correlated with disease activity and specific clinical features. NLR, CAR, SII, and SIRI may be an aid in differentiating ASS from DM/PM and maybe promising biomarkers for ASS.

Predicting the death of patients with anti-melanoma differentiation-associated protein-5-positive dermatomyositis-associated interstitial lung disease: A systematic review and meta-analysis

OBJECTIVES

To investigate the risk factors for death in anti-melanoma differentiation-associated protein-5-positive dermatomyositis-associated interstitial lung disease (ILD).

METHODS

Studies were identified by searching PubMed, Embase, Web of Science, and Cochrane Library. We calculated pooled risk ratios (RRs) or standardized mean differences (SMDs) and 95% confidence intervals (CIs) using random-effects models.

RESULTS

Twenty studies were selected. Factors that may increase death risk included older age (SMD: 0.62, 95% CI: 0.42-0.81), elevated Krebs von den Lungen-6 (SMD: 0.66, 95% CI: 0.47-0.86), lactate dehydrogenase (SMD: 0.87, 95% CI: 0.72-1.02), C-reactive protein (SMD: 0.62, 95% CI: 0.44-0.80), ferritin (SMD: 0.93, 95% CI: 0.71-1.15), creatine kinase (SMD: 0.28, 95% CI: 0.13-0.44), neutrophil (SMD: 0.34, 95% CI: 0.04-0.64), neutrophil-to-lymphocyte ratio (SMD: 0.52, 95% CI: 0.24-0.79), aspartate aminotransferase (SMD: 0.70, 95% CI: 0.45-0.94), shorter disease duration (SMD: -0.44, 95% CI: -0.67 to -0.21), rapidly progressive ILD (RR: 4.08, 95% CI: 3.01-5.54), fever (RR: 1.98, 95% CI: 1.46-2.69), dyspnoea (RR: 1.63, 95% CI: 1.32-2.02), and anti-Ro52 antibody positive (RR: 1.28, 95% CI: 1.11-1.49). Female (RR: 0.86, 95% CI: 0.78-0.94), increased albumin (SMD: -1.20, 95% CI: -1.76 to -0.64), lymphocyte (SMD: -0.49, 95% CI: -0.67 to -0.30), and arthralgia (RR: 0.53, 95% CI: 0.37-0.78) were protective factors.

CONCLUSION

Older age, shorter disease duration, rapidly progressive ILD, fever, dyspnoea, anti-Ro52 antibody positive, and some inflammatory markers were risk factors for death in patients with anti-melanoma differentiation-associated protein-5-positive dermatomyositis-associated ILD.

Prognostic significance of antifibrotic agents in idiopathic pulmonary fibrosis after initiation of long-term oxygen therapy

BACKGROUND AND AIM

Idiopathic pulmonary fibrosis (IPF) is a fatal and progressive interstitial lung disease with varying degrees of hypoxemia. Long-term oxygen therapy (LTOT) is frequently used to treat hypoxemia, however the prognostic factors for better survival in IPF patients after initiation of LTOT remain unknown.

METHODS

We retrospectively investigated favorable factors of survival in consecutive 55 IPF patients with chronic respiratory failure who were introduced LTOT.

RESULTS

The 6-, 12-, 18-, and 24-month survival rates in IPF patients after introduction of LTOT were 70.9%, 49.0%, 45.2%, and 32.3%, respectively. Univariate analysis demonstrated that low Glasgow Prognostic Score (GPS) (hazard ratio [HR] 0.482, p=0.043) and treatment with antifibrotic agents (HR 0.401, p=0.013) were associated with favorable survival, while multivariate analysis revealed that treatment with antifibrotic agents was the independent predictor (HR 0.449, p=0.032). Moreover, IPF patients treated with antifibrotic agents with LTOT had significantly longer survival than those without antifibrotic agents (p = 0.0106).

CONCLUSION

In IPF patients who were introduced LTOT, treatment with antifibrotic agents was the independent factor for favorable survival. Treatment with antifibrotic agents may improve prognosis of IPF even after initiation of LTOT.

Development of a novel predictive model for interstitial lung disease in ANCA-associated vasculitis prognostications within the Chinese population

Antineutrophil cytoplasmic antibody vasculitis-associated interstitial lung disease (AAV-ILD) is a potentially life-threatening disease. However, very little research has been done on the condition's mortality risk. Hence, our objective is to find out the factors influencing the prognosis of AAV-ILD and employ these findings to create a nomogram model. Patients with AAV-ILD who received treatment at the First Affiliated Hospital of Zhengzhou University during the period from March 1, 2011, to April 1, 2022 were selected for this research. The development of nomogram entailed a synergistic integration of univariate, Lasso, and multivariate Cox regression analyses. Internal validation ensued through bootstrap techniques involving 1000 re-sampling iterations. Discrimination and calibration were assessed utilizing Harrell's C-index, receiver operating characteristic (ROC) curve, and calibration curve. Model performance was evaluated through integrated discrimination improvement (IDI), net reclassification improvement (NRI), and likelihood ratio test. The net benefit of the model was evaluated using decision curve analysis (DCA). A cohort comprising 192 patients was enrolled for analysis. Throughout observation period, 32.29% of the population died. Key factors such as cardiac involvement, albumin, smoking history, and age displayed substantial prognostic relevance in AAV-ILD. These factors were incorporated to craft a predictive nomogram. Impressively, the model exhibited robust performance, boasting a Harrell's C index of 0.826 and an AUC of 0.940 (95% CI 0.904-0.976). The calibration curves depicted a high degree of harmony between predicted outcomes and actual observations. Significantly enhancing discriminative ability compared to the ILD-GAP model, the nomogram was validated through the IDI, NRI, and likelihood ratio test. DCA underscored the superior predictive value of the predictive model over the ILD-GAP model. The internal validation further affirmed this efficacy, with a mean Harrell's C-index of 0.815 for the predictive model. The nomogram model can be employed to predict the prognosis of patients with AAV-ILD. Moreover, the model performance is satisfactory. In the future, external datasets could be utilized for external validation.

The prevalence and effects of treatments of rapidly progressive interstitial lung disease of dermatomyositis/polymyositis adults: A systematic review and meta-analysis

Rapidly progressive interstitial lung disease (RP-ILD) clearly harms the prognoses of dermatomyositis/polymyositis (DM/PM) patients, however there is a dearth of numerical prevalence and therapy comparison in this field. Therefore, the purpose of this study was to determine the prevalence of RP-ILD in DM/PM patients and compare prognoses, including remission rate and survival data, between treatments. Studies with reports of RP-ILD in DM/PM patients and studies with definite remission and/or survival data of DM/PM-RP-ILD were included in the study. Data sources were Pubmed, Embase, and Cochrane Library without language restrictions. Two authors (WHL and WWQ) extracted independently the data. Estimates of the pooled effects were calculated using the Mantel-Haenszel technique (random effects). The prevalence meta-analysis included 18 papers with 6058 DM/PM patients, and 31 papers were analyzed for treatment effects, including remission rate, 6-month survival rate, 1-year survival rate, and 5-year survival rate. Database search yielded 1816 articles. In the DM/PM population, the combined prevalence of RP-ILD was 8.9% (95% CI, 5.8% to 12.1%). Patients with RP-ILD have a remission rate of 58.4% (95% CI, 47.3% to 69.4%), with biologic treatment with the highest remission rate, followed by triple therapy (defined as adding a third intravenous medication, including cyclophosphamide and immunoglobulin). Biologics therapy had the highest overall survival rate at six months (95% CI, 49.8% to 73.9%), followed by cDMARDs, plasma exchange, and triple therapy. The 1-year survival rate was 77.4% (95% CI, 66.7% to 88.1%), and triple therapy and cDMARDs had the best survival rates. The 5-year survival rate was 40.0% (95% CI, 10.0% to 69.9%). The prevalence of RP-ILD in DM/PM was approximately 8.9%, with a poor long-term prognosis. The use of biological agents appears to provide the best therapeutic outcomes, providing RP-ILD management with a novel evidence-based therapy. The use of strong immunosuppressive treatments may result in life-threatening side effects, thus clinicians must closely monitor the condition.

Acute Exacerbations of Interstitial Lung Diseases: Focus on Biomarkers

Interstitial lung diseases (ILDs) are a large group of pulmonary disorders characterized histologically by the cardinal involvement of the pulmonary interstitium. The prototype of ILDs is idiopathic pulmonary fibrosis (IPF), an incurable disease characterized by progressive distortion and loss of normal lung architecture through unchecked collagen deposition. Acute exacerbations are dramatic events during the clinical course of ILDs, associated with high morbidity and mortality. Infections, microaspiration, and advanced lung disease might be involved in the pathogenesis of acute exacerbations. Despite clinical scores, the prediction of the onset and outcome of acute exacerbations is still inaccurate. Biomarkers are necessary to characterize acute exacerbations better. We review the evidence for alveolar epithelial cell, fibropoliferation, and immunity molecules as potential biomarkers for acute exacerbations of interstitial lung disease.

Molecular signature of neutrophil extracellular trap mediating disease module in idiopathic inflammatory myopathy

The rarity and heterogeneity of idiopathic inflammatory myopathy (IIM) pose challenges for researching IIM in affected individuals. We analyzed integrated transcriptomic datasets obtained using muscle tissues from patients with five distinct IIM subtypes to investigate the shared and distinctive cellular and molecular characteristics. A transcriptomic dataset of muscle tissues from normal controls (n = 105) and patients with dermatomyositis (n = 89), polymyositis (n = 33), inclusion body myositis (n = 121), immune-mediated necrotizing myositis (n = 75), and anti-synthetase syndrome (n = 18) was used for differential gene-expression analysis, functional-enrichment analysis, gene set-enrichment analysis, disease-module identification, and kernel-based diffusion scoring. Damage-associated molecular pattern-associated pathways and neutrophil-mediated immunity were significantly enriched across different IIM subtypes, although their activities varied. Interferons-signaling pathways were differentially activated across all five IIM subtypes. In particular, neutrophil extracellular trap (NET) formation was significantly activated and correlated with Fcγ R-mediated signaling pathways. NET formation-associated genes were key for establishing disease modules, and FCGRs, C1QA, and SERPINE1 markedly perturbed the disease modules. Integrated transcriptomic analysis of muscle tissues identified NETs as key components of neutrophil-mediated immunity involved in the pathogenesis of IIM subtypes and, thus, has therapeutically targetable value.

Low serum level of citrullinated histone H3 in patients with dermatomyositis

OBJECTIVES

We aimed at analyzing the serum levels of citrullinated histone H3 (CitH3) in patients with dermatomyositis (DM) and their association with disease activity.

METHODS

Serum CitH3 levels were measured using enzyme-linked immunosorbent assays in serum samples obtained from 93 DM patients and 56 healthy controls (HCs). Receiver operating characteristic (ROC) curve analysis was performed to evaluate the discriminant capacity of CitH3 and other disease variables. The association between CitH3 and disease variables was analyzed using Pearson's rank correlation.

RESULTS

Serum CitH3 level was significantly lower in DM patients than in HCs (p < 0.001). The ROC curve analysis revealed that CitH3 strongly discriminated DM patients from HCs (area under the curve [AUC], 0.86), and a combination of CitH3 and the ratio of neutrophil to lymphocyte counts (NLR) showed a greater diagnostic value (AUC, 0.92). Serum CitH3 levels were markedly lower in DM patients with normal muscle enzyme levels than in HCs (all p < 0.001), and when compared to an elevated group, the CitH3 levels were comparable (all p > 0.05). The CitH3 levels showed no difference between DM in active and remission groups. However, in a paired test with 18 hospitalized DM patients, the CitH3 levels were higher in remission state than in active state. Moreover, the CitH3 levels showed no correlation with disease variables that were associated with the disease activity of DM.

CONCLUSIONS

Serum CitH3 level may serve as a useful biochemical marker for screening patients with DM from HCs, while its role in monitoring DM disease activity requires further research.

The prognostic role of C-reactive protein to albumin ratio and anti-MDA5 antibody-positive in idiopathic inflammatory myopathy: a retrospective study

This cohort study aimed to identify the characteristics and risk factors of adult idiopathic inflammatory myopathy-associated interstitial lung disease (IIM-ILD) and further explore the prognostic factors of IIM-ILD. We extracted data regarding 539 patients with laboratory-confirmed idiopathic inflammatory myopathy (IIM) with or without interstitial lung disease (ILD) from the Second Xiangya Hospital of Central South University between January 2016 and December 2021. The regression analysis was conducted to identify the possible risk factors for ILD as well as mortality. Of 539 IIM patients, 343 (64.6%) were diagnosed with IIM-ILD. The median (IQR) baseline neutrophil-to-lymphocyte ratio (NLR), C-reactive protein to albumin ratio (CAR) and ferritin were 4.1371 (2.6994-6.8143), 0.1685 (0.0641-0.5456) and 393.6 (210.6-532.2), respectively. Risk factors associated with IIM-ILD were older age (p = 0.002), arthralgia (p = 0.014), lung infection (p = 0.027), hemoglobin (p = 0.022), high CAR (p = 0.014), anti-aminoacyl-tRNA synthetase (anti-ARS) antibody-positive (p < 0.001), and anti-MDA5 antibody-positive (p < 0.001). The IIM-ILD patients whose age at diagnosis of disease ≥ 59.5 (HR = 2.673, 95% CI 1.588-4.499, p < 0.001), NLR ≥ 6.6109 (HR = 2.004, 95% CI 1.193-3.368, p = 0.009), CAR ≥ 0.2506 (HR = 1.864, 95% CI 1.041-3.339, p = 0.036), ferritin ≥ 397.68 (HR = 2.451, 95% CI 1.245-4.827, p = 0.009) and anti-MDA5 antibody-positive (HR = 1.928, 95% CI 1.123-3.309, p = 0.017) had a higher mortality rate. High CAR and anti-MDA5 antibody-positive are more likely to be associated with a high mortality rate of IIM-ILD, which can be used as serum biomarkers, especially the CAR, a simple, objective tool to assess the prognosis of IIM.

Blood Neutrophil Count and Neutrophil-to-Lymphocyte Ratio for Prediction of Disease Progression and Mortality in Two Independent Systemic Sclerosis Cohorts

OBJECTIVE

To assess the predictive significance of blood neutrophil count and the ratio between neutrophil and lymphocyte count (neutrophil-to-lymphocyte ratio [NLR]) for disease severity and mortality in systemic sclerosis (SSc).

METHODS

Neutrophil and lymphocyte counts were prospectively measured in the Genetics versus Environment in Scleroderma Outcome Study (GENISOS) and the Scleroderma Lung Study II (SLS II). Forced vital capacity percent predicted (FVC%) and modified Rodnan skin thickness score (MRSS) were used as surrogate measures for disease severity. Longitudinal analyses were performed using generalized linear mixed models. Cox proportional hazards models evaluated the predictive significance of these cell counts for mortality.

RESULTS

Of the 447 SSc patients in the GENISOS cohort at the time of analysis, 377 (84.3%) had available baseline blood neutrophil and lymphocyte counts. Higher baseline neutrophil count and NLR predicted lower serially obtained FVC% (b = -4.74, P = 0.009 and b = -2.68, P = 0.028, respectively) and higher serially obtained MRSS (b = 4.07, P < 0.001 and b = 2.32, P < 0.001, respectively). Longitudinal neutrophil and NLR measurements also significantly correlated with lower concurrently obtained FVC% measurements and higher concurrently obtained MRSS. Baseline neutrophil count and NLR predicted increased risk of long-term mortality, even after adjustment for baseline demographic and clinical factors (hazard ratio [HR] 1.42, P = 0.02 and HR 1.48, P < 0.001, respectively). The predictive significance of higher baseline neutrophil count and NLR for declining FVC% and increased long-term mortality was confirmed in the SLS II.

CONCLUSION

Higher blood neutrophil count and NLR are predictive of more severe disease course and increased mortality, indicating that these easily obtainable laboratory studies might be a reflection of pathologic immune processes in SSc.

Elevated platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in patients with polymyositis/dermatomyositis: a retrospective study

OBJECTIVES

This study aimed to examine the diagnostic and prognostic value of the platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) in patients with polymyositis/dermatomyositis (PM/DM).

METHOD

Clinical data of 200 patients with PM/DM and 204 healthy controls were retrospectively reviewed. We examined whether the PLR and NLR were associated with PM/DM.

RESULTS

The PLR and NLR were higher in patients with PM/DM than in controls (both P < 0.001). The PLR and NLR were higher in patients with DM than in those with PM (both P < 0.01). The PLR was higher in the anti-melanoma differentiation-associated protein-5 (anti-MDA5) ⁺ PM/DM group than in the anti-MDA5^- PM/DM group (P = 0.002). The NLR in non-survivors was higher than that in survivors (P = 0.01). The NLR was positively correlated with the occurrence of interstitial lung disease (ILD). The PLR and NLR were independent predictors of PM/DM, as well as risk factors (both P < 0.001). Moreover, the NLR had a predictive value for PM/DM-ILD and was closely related to mortality (P = 0.033, P = 0.003, respectively).

CONCLUSIONS

Patients with PM/DM have a higher NLR and PLR than healthy controls, especially in those with anti-MDA5⁺. The PLR and NLR are independent risk factors for PM/DM and have some predictive value. The NLR is correlated with ILD and associated with an increased risk of mortality in patients with PM/DM. The NLR and PLR may be simple, economical, and accurate diagnostic and prognostic markers for patients with PM/DM. Key points • The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been studied in numerous inflammatory diseases as potential markers, but their clinical significance in polymyositis/dermatomyositis (PM/DM) remains unclear. • We examined the changes in the NLR and PLR between patients with PM/DM and healthy controls, as well as their association with mortality, interstitial lung disease, and anti-melanoma differentiation-associated protein-5. • Patients with PM/DM may benefit from using the NLR and PLR as simple, economical, and accurate diagnostic and prognostic markers.

Clinical and imagenologic significance of the neutrophil-to-lymphocyte ratio in neuromyelitis optica spectrum disorder: A systematic review with meta-analysis

BACKGROUND

Recently, the neutrophil-lymphocyte ratio (NLR) has become a biomarker for assessing inflammatory stress and prognosis in different diseases.

OBJECTIVE

We aimed to conduct a systematic review and meta-analysis to summarize the current evidence on the capacity of the NLR to serve as a biomarker in neuromyelitis optica spectrum disorder (NMOSD).

METHODS

Through a comprehensive systematic search up to December 2021 and using the search terms "neutrophil-to-lymphocyte ratio" and "neuromyelitis optica spectrum disorder" we selected studies evaluating NLR values in NMOSD patients. A meta-analysis was planned, and a narrative synthesis was performed when this was not possible. Subgroup and sensitivity analyses were planned. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to assess certainty of the evidence.

RESULTS

Six studies were included (1036 patients). A significant increase in the NLR was observed between NMOSD patients and healthy controls with high heterogeneity (MD: 1.04; 95% CI: 0.76; 1.32; I2 = 59%). Regarding NMOSD prognosis, relapse (OR: 1.33 -OR: 2.14) was evaluated as being related to NLR with low certainty. An association with Expanded Disability Status Scale (EDSS) score ≥4 (OR: 1.23 -OR: 1.43) was reported with moderate certainty. An association with the occurrence of lesions on MRI was reported with an OR of 1.52.

CONCLUSION

We found the NLR to be useful as a biomarker of NMOSD as it was significantly increased in the patient group compared to the healthy control group with high certainty. Additionally, the NLR was applicable as an indicator of poor prognosis with low to moderate certainty.

Multi-center evaluation of baseline neutrophil-to-lymphocyte (NLR) ratio as an independent predictor of mortality and clinical risk stratifier in idiopathic pulmonary fibrosis

Background

Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal disorder with a variable disease trajectory. The aim of this study was to assess the potential of neutrophil-to-lymphocyte ratio (NLR) to predict outcomes in IPF.

Methods

We adopted a two-stage discovery (n = 71) and validation (n = 134) design using patients from the UCL partners (UCLp) cohort. We then combined discovery and validation cohorts and included an additional 794 people with IPF, using real-life data from 5 other UK centers, to give a combined cohort of 999 patients. Data were collected from patients presenting over a 13-year period (2006-2019) with mean follow up of 3.7 years (censoring: 2018-2020).

Findings

In the discovery analysis, we showed that high values of NLR (>/ = 2.9 vs < 2.9) were associated with increased risk of mortality in IPF (HR 2.04, 95% CI 1.09-3.81, n = 71, p = 0.025). This was confirmed in the validation (HR 1.91, 95% CI 1.15-3.18, n = 134, p = 0.0114) and combined cohorts (HR 1.65, n = 999, 95% CI 1.39-1.95; p < 0·0001). NLR correlated with GAP stage and GAP index (p < 0.0001). Stratifying patients by NLR category (low/high) showed significant differences in survival for GAP stage 2 (p < 0.0001), however not for GAP stage 1 or 3. In a multivariate analysis, a high NLR was an independent predictor of mortality/progression after adjustment for individual GAP components and steroid/anti-fibrotic use (p < 0·03). Furthermore, incorporation of baseline NLR in a modified GAP-stage/index, GAP-index/stage-plus, refined prognostic ability as measured by concordance (C)-index.

Interpretation

We have identified NLR as a widely available test that significantly correlates with lung function, can predict outcomes in IPF and refines cohort staging with GAP. NLR may allow timely prioritisation of at-risk patients, even in the absence of lung function.

Funding

Breathing Matters, GSK, CF Trust, BLF-Asthma, MRC, NIHR Alpha-1 Foundation.

Predictors of Mortality in COVID-19 patients: An observational study

Objectives

To identify the factors that affect outcome in COVID-19 patients in the Pakistani population.

Methods

A total of 225 patients of COVID-19 RT-PCR proven were included during November, 2020 to June, 2021 in this cross-sectional study. They were stratified into different disease severity categories as per WHO guidelines. The characteristics of survivors and non survivors were recorded and then compared to draw conclusions.

Results

Mean age was 59 years. Majority of the patients were male (68%) and the overall mortality rate was 30.1%. The non survivors were more likely to be female, had a greater number of comorbidities, had a higher respiratory rate and lower oxygen saturations at presentation and had a greater frequency of invasive mechanical ventilation. Non survivors had higher values of TLC, CRP, D-dimers and lower values of Hemoglobin and Platelets. The non survivors had higher incidence of ARDS, Septic shock and Multiorgan involvement. A higher CURB-65 score was observed in non survivors as compared to those who survived. Multivariate analysis showed that female gender, presence of and higher number of comorbid conditions and a higher CURB-65 score was linked with mortality.

Conclusion

Results are compatible with international studies; increasing age, number of comorbid conditions and high inflammatory markers are associated with increased mortality. Our study had an exception that female gender had higher mortality as compared to men.

Inflammatory myopathies and beyond: The dual role of neutrophils in muscle damage and regeneration

Skeletal muscle is one of the most abundant tissues of the human body and is responsible for the generation of movement. Muscle injuries can lead to severe disability. Skeletal muscle is characterized by an important regeneration capacity, which is possible due to the interaction between the myoblasts and immune cells. Neutrophils are fundamental as inducers of muscle damage and as promoters of the initial inflammatory response which eventually allows the muscle repair. The main functions of the neutrophils are phagocytosis, respiratory burst, degranulation, and the production of neutrophil extracellular traps (NETs). An overactivation of neutrophils after muscle injuries may lead to an expansion of the initial damage and can hamper the successful muscle repair. The importance of neutrophils as inducers of muscle damage extends beyond acute muscle injury and recently, neutrophils have become more relevant as part of the immunopathogenesis of chronic muscle diseases like idiopathic inflammatory myopathies (IIM). This heterogeneous group of systemic autoimmune diseases is characterized by the presence of muscle inflammation with a variable amount of extramuscular features. In IIM, neutrophils have been found to have a role as biomarkers of disease activity, and their expansion in peripheral blood is related to certain clinical features like interstitial lung disease (ILD) and cancer. On the other hand, low density granulocytes (LDG) are a distinctive subtype of neutrophils characterized by an enhanced production of NETs. These cells along with the NETs have also been related to disease activity and certain clinical features like ILD, vasculopathy, calcinosis, dermatosis, and cutaneous ulcers. The role of NETs in the immunopathogenesis of IIM is supported by an enhanced production and deficient degradation of NETs that have been observed in patients with dermatomyositis and anti-synthetase syndrome. Finally, new interest has arisen in the study of other phenotypes of LDG with a phenotype corresponding to myeloid-derived suppressor cells, which were also found to be expanded in patients with IIM and were related to disease activity. In this review, we discuss the role of neutrophils as both orchestrators of muscle repair and inducers of muscle damage, focusing on the immunopathogenesis of IIM.

Neutrophil to lymphocyte ratio and in-hospital mortality among patients with SARS-CoV-2: A retrospective study

The goal of this study was to investigate in-hospital mortality in patients suffering from acute respiratory syndrome coronavirus 2 (SARS-CoV-2) relative to the neutrophil to lymphocyte ratio (NLR) and to determine if there are gender disparities in outcome. Between February 26 and September 8, 2020, patients having SARS-CoV-2 infection were enrolled in this retrospective cohort research, which was categorized by NLR levels ≥9 and < 9. In total, 6893 patients were involved included of whom6591 had NLR <9, and 302 had NLR ≥9. The age of most of the patients in the NLR<9 group was 50 years, on the other hand, the age of most of the NLR ≥9 group patients was between 50 and 70 years. The majority of patients in both groups were male 2211 (66.1%). The ICU admission time and mortality rate for the patients with NLR ≥9 was significantly higher compared to patients with NLR <9. Logistic regression's outcome indicated that NLR ≥9 (odds ratio (OR), 24.9; 95% confidence interval (CI): 15.5–40.0; p < 0.001), male sex (OR, 3.5; 95% CI: 2.0–5.9; p < 0.001) and haemoglobin (HB) (OR, 0.95; 95% CI; 0.94–0.96; p < 0.001) predicted in-hospital mortality significantly. Additionally, Cox proportional hazards analysis (B = 4.04, SE = 0.18, HR = 56.89, p < 0.001) and Kaplan–Meier survival probability plots also indicated that NLR>9 had a significant effect on mortality. NLR ≥9 is an independent predictor of mortality(in-hospital) among SARS-CoV-2 patients.

•

The main finding of this study is that NLR is an autonomous predictor of in-hospital mortality in patients with SARS-CoV-2.

•

Fatality in SARS-CoV-2 patients with NLR >9 was 25 times higher than that in patients with NLR <9.

•

Patients with NLR >9, the average length of ICU stay was higher.

•

Mortality rate in males was high compared to females with NLR>9.

Charlson comorbidity index, neutrophil-to-lymphocyte ratio and undertreatment with renin-angiotensin-aldosterone system inhibitors predict in-hospital mortality of hospitalized COVID-19 patients during the omicron dominant period

Purpose

To investigate the clinical predictors of in-hospital mortality in hospitalized patients with Coronavirus disease 2019 (COVID-19) infection during the Omicron period.

Methods

All consecutive hospitalized laboratory‐confirmed COVID-19 patients between January and May 2022 were retrospectively analyzed. All patients underwent accurate physical, laboratory, radiographic and echocardiographic examination. Primary endpoint was in-hospital mortality.

Results

74 consecutive COVID-19 patients (80.0 ± 12.6 yrs, 45.9% males) were included. Patients who died during hospitalization (27%) and those who were discharged alive (73%) were separately analyzed. Compared to patients discharged alive, those who died were significantly older, with higher comorbidity burden and greater prevalence of laboratory, radiographic and echographic signs of pulmonary and systemic congestion. Charlson comorbidity index (CCI) (OR 1.76, 95%CI 1.07-2.92), neutrophil-to-lymphocyte ratio (NLR) (OR 1.24, 95%CI 1.10-1.39) and absence of angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) therapy (OR 0.01, 95%CI 0.00-0.22) independently predicted the primary endpoint. CCI ≥7 and NLR ≥9 were the best cut-off values for predicting mortality. The mortality risk for patients with CCI ≥7, NLR ≥9 and not in ACEI/ARBs therapy was high (86%); for patients with CCI <7, NLR ≥9, with (16.6%) or without (25%) ACEI/ARBs therapy was intermediate; for patients with CCI <7, NLR <9 and in ACEI/ARBs therapy was of 0%.

Conclusions

High comorbidity burden, high levels of NLR and the undertreatment with ACEI/ARBs were the main prognostic indicators of in-hospital mortality. The risk stratification of COVID-19 patients at hospital admission would help the clinicians to take care of the high-risk patients and reduce the mortality.

Clinical Features of Dermatomyositis/Polymyositis with Anti-MDA5 Antibody Positivity

This paper aims to investigate the clinical and laboratory test characteristics of patients with anti-MDA5 antibody-positive PM/DM by analyzing the clinical characteristics, laboratory test results, and 1-year survival rate of patients with anti-MDA5 antibody-positive PM/DM in polymyositis (PM) and dermatomyositis (DM). To further investigate the impact of positive anti-MDA5 antibodies on the prognosis of PM/DM patients. According to the anti-MDA5 antibody test results, 18 cases with positive anti-MDA5 antibodies were in the positive group and 46 cases with negative anti-MDA5 antibodies were in the negative group. The clinical manifestations, laboratory tests, treatment protocols, and prognostic risk factors were collected for both groups. The chi-square test, Mann–Whitney method, Fisher test, t-test, Kaplan–Meier method, and Log-rank test were used for statistical analysis. Anti-MDA5 antibody positivity was more common in patients with DM/CADM. With no statistically significant differences in age and sex ratio between the two groups, The differences in erythrocyte sedimentation rate (ESR), ferritin (Fer), and creatine kinase (CK) levels in the positive group were statistically significant compared with the negative group. Clinically, the positive group was more prone to arthralgia, skin rash, and interstitial pneumonia.

Significance of hemogram‐derived ratios for predicting in‐hospital mortality in COVID‐19: A multicenter study

Background

To address the problem of resource limitation, biomarkers having a potential for mortality prediction are urgently required. This study was designed to evaluate whether hemogram‐derived ratios could predict in‐hospital deaths in COVID‐19 patients.

Materials and Methods

This multicenter retrospective study included hospitalized COVID‐19 patients from four COVID‐19 dedicated hospitals in Sylhet, Bangladesh. Data on clinical characteristics, laboratory parameters, and survival outcomes were analyzed. Logistic regression models were fitted to identify the predictors of in‐hospital death.

Results

Out of 442 patients, 55 (12.44%) suffered in‐hospital death. The proportion of male was higher in nonsurvivor group (61.8%). The mean age was higher in nonsurvivors (69 ± 13 vs. 59 ± 14 years, p < 0.001). Compared to survivors, nonsurvivors exhibited higher frequency of comorbidities, such as chronic kidney disease (34.5% vs. 15.2%, p ≤ 0.001), chronic obstructive pulmonary disease (23.6% vs. 10.6%, p = 0.011), ischemic heart disease (41.8% vs. 19.4%, p < 0.001), and diabetes mellitus (76.4% vs. 61.8%, p = 0.05). Leukocytosis and lymphocytopenia were more prevalent in nonsurvivors (p < 0.05). Neutrophil‐to‐lymphocyte ratio (NLR), derived NLR (d‐NLR), and neutrophil‐to‐platelet ratio (NPR) were significantly higher in nonsurvivors (p < 0.05). After adjusting for potential covariates, NLR (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.009‐1.08), d‐NLR (OR 1.08; 95% CI 1.006‐1.14), and NPR (OR 1.20; 95% CI 1.09‐1.32) have been found to be significant predictors of mortality in hospitalized COVID‐19 patients. The optimal cut‐off points for NLR, d‐NLR, and NPR for prediction of in‐hospital mortality for COVID‐19 patients were 7.57, 5.52 and 3.87, respectively.

Conclusion

Initial assessment of NLR, d‐NLR, and NPR values at hospital admission is of good prognostic value for predicting mortality of patients with COVID‐19.

The Functional Roles of RNAs Cargoes Released by Neutrophil-Derived Exosomes in Dermatomyositis

Dermatomyositis (DM) is an idiopathic inflammatory myopathy characterized by cutaneous manifestations. We first identified the profiles of noncoding RNAs (lncRNAs and miRNAs) in peripheral neutrophil exosomes (EXOs) of DM patients and explored their potential functional roles. Bioinformatics analyses were performed with R packages. Real-time quantitative PCR was used to validate the altered RNAs in DM neutrophil EXO-stimulated human dermal microvascular endothelial cells (HDMECs) and human skeletal muscle myoblasts (HSkMCs). In DM neutrophil EXOs, 124 upregulated lncRNAs (with 1,392 target genes), 255 downregulated lncRNAs (with 1867 target genes), 17 upregulated miRNAs (with 2,908 target genes), and 15 downregulated miRNAs (with 2,176 target genes) were identified. GO analysis showed that the differentially expressed (DE) lncRNAs and DE miRNAs participated in interleukin-6 and interferon-beta production, skeletal muscle cell proliferation and development, and endothelial cell development and differentiation. KEGG analysis suggested that DE lncRNAs and DE miRNAs were enriched in the PI3K–Akt, MAPK, AMPK and FoxO signalling pathways. Many novel and valuable DE lncRNAs and DE miRNAs interacted and cotargeted in the PI3K–Akt, MAPK, AMPK and FoxO signalling pathways. Our study suggests that neutrophil EXOs participate in DM pathogenesis through lncRNAs and miRNAs in the PI3K–Akt, MAPK, AMPK and FoxO signalling pathways.

Lymphocyte immunophenotyping in inflammatory myositis: a review

PURPOSE OF REVIEW

This is a comprehensive review of the current knowledge on predominant immune cell phenotypes involved in idiopathic inflammatory myopathies (IIM).

RECENT FINDINGS

Major circulating immune cell subpopulations described in IIM encompass the lymphocyte compartment. An unbalance in T cell subsets seems to consistently affect the peripheral and muscle compartment, with a predominance of CD4+ T and B cells in dermatomyositis, CD8+ T cells in polymyositis/inclusion body myositis (IBM) and novel findings highlighting novel proinflammatory T subsets, that is, CD8+Tbet+ and CD28- T cells across different IIM subsets. On the other hand, an impairment in Treg cells number and function has been described especially across polymyositis/dermatomyositis and IBM. Total T follicular helper (Tfh) cells, increased in immune-mediated necrotizing myopathy, skewed toward Tfh2 and Tfh17 in dermatomyositis, polymyositis, and juvenile dermatomyositis. B cell compartment is more rarely described in IIM, yet an unbalance in this pool is as well likely. Evidence of plasma cells increased in polymyositis, dermatomyositis, IBM, and Bregs decreased in dermatomyositis have been reported. Perturbations in the memory and naïve subsets are common in dermatomyositis/polymyositis and antisynthetase syndrome.

SUMMARY

Protean immune cell abnormalities characterize different IIM subsets, reflecting the complexity of these autoimmune conditions. A deeper understanding of B-cell and T-cell immunophenotyping may promote early diagnosis and identification of new potential therapeutic targets.

Neutrophils as Drivers of Immune Dysregulation in Autoimmune Diseases with Skin Manifestations

Dysregulation in the phenotype and function of neutrophils may play important roles in the initiation and perpetuation of autoimmune responses, including conditions affecting the skin. Neutrophils can have local and systemic effects on innate and adaptive immune cells as well as on resident cells in the skin, including keratinocytes (KCs). Aberrant formation/clearance of neutrophil extracellular traps (NETs) in systemic autoimmunity and chronic inflammatory diseases have been associated with the externalization of modified autoantigens in peripheral blood and tissues. NETs can impact the function of many cells, including macrophages, lymphocytes, dendritic cells, fibroblasts, and KCs. Emerging evidence has unveiled the pathogenic key roles of neutrophils in systemic lupus erythematosus, idiopathic inflammatory myopathies, psoriasis, hidradenitis suppurativa, and other chronic inflammatory conditions. As such, neutrophil-targeting strategies represent promising therapeutic options for these diseases.

Revealing the therapeutic targets and molecular mechanisms of emodin-treated coronavirus disease 2019 via a systematic study of network pharmacology

Emodin has shown pharmacological effects in the treatment of infection with severe acute respiratory syndrome coronavirus-2, which leads to coronavirus disease 2019 (COVID-19). Thus, we speculated that emodin may possess anti-COVID-19 activity. In this study, using bioinformatics databases, we screened and harvested the candidate genes or targets of emodin and COVID-19 prior to the determination of pharmacological targets and molecular mechanisms of emodin against COVID-19. We discovered core targets for the treatment of COVID-19, including mitogen-activated protein kinase 1 (MAPK1), tumor protein (TP53), tumor necrosis factor (TNF), caspase-3 (CASP3), epidermal growth factor receptor (EGFR), vascular endothelial growth factor A (VEGFA), interleukin 1B (IL1B), mitogen-activated protein kinase 14 (MAPK14), prostaglandin-endoperoxide synthase 2 (PTGS2), B-cell lymphoma-2-like protein 1 (BCL2L1), interleukin-8 (CXCL8), myeloid cell leukemia-1 (MCL1), and colony stimulating factor 2 (CSF2). The GO analysis of emodin against COVID-19 mainly included cytokine-mediated signaling pathway, response to lipopolysaccharide, response to molecule of bacterial origin, developmental process involved in reproduction, and reproductive structure development. The KEGG results exhibited that the molecular pathways mainly included IL-17 signaling pathway, AGE-RAGE signaling pathway in diabetic complications, TNF signaling pathway, pertussis, proteoglycans in cancer, pathways in cancer, MAPK signaling pathway, NOD-like receptor signaling pathway, NF-kappa B signaling pathway, etc. Also, molecular docking results revealed the docking capability between emodin and COVID-19 and the potential pharmacological activity of emodin against COVID-19. Taken together, these findings uncovered the targets and pharmacological mechanisms of emodin for treating COVID-19 and suggested that the vital targets might be used as biomarkers against COVID-19.

Analysis of risk factors of interstitial lung disease and mortality rates in Chinese patients with idiopathic inflammatory myopathy

Aim

To investigate the risk factors for interstitial lung disease (ILD) and prognosis in patients with idiopathic inflammatory myopathy (IIM).

Methods

A retrospective longitudinal study was performed in patients diagnosed with IIM between January 2012 and December 2018.

Results

The study cohort included 91 men and 195 women who were classified as having dermatomyositis (DM, n = 183), polymyositis (PM, n = 77), or clinical amyopathic DM (CADM, n = 26). ILD was identified in 46.5% (n = 133) of patients with IIM. The independent risk factors for ILD were age at disease onset, presence of anti‐Ro‐52 antibody, Gottron's papules, elevated serum immunoglobulin M levels and hypoalbuminemia. Older age at disease onset, ILD, malignancy, and increased serum aspartate aminotransferase and neutrophil‐to‐lymphocyte ratio (NLR) were identified as the independent predictors for mortality, whereas elevated serum albumin level was associated with a better prognosis. A total of 73 deaths (25.5%) occurred after a median follow‐up time of 33 months. Infection (49.3%) was the leading cause of death. In the overall cohort, the 1‐year, 5‐year and cumulative survival rates were 83.2%, 74.2% and 69.4%, respectively. The receiver operating characteristic curve indicated that the optimal cut‐off value of NLR for predicting death in IIM was 6.11.

Conclusion

IIM patients have a poor prognosis with substantial mortality, especially in patients who have older age at onset, ILD, malignancy and higher NLR. Close monitoring and aggressive therapies are required in patients having poor predictive factors.

The long-term prognosis of pneumomediastinum associated with dermatomyositis: a two-centre retrospective cohort study

OBJECTIVES

Pneumomediastinum (PnM) is a rare but life-threatening complication of DM. The present study aims to characterize the long-term prognosis and prognostic factors of DM-associated PnM.

METHODS

Inpatients with DM-associated PnM were retrospectively enrolled from two tertiary referral centres for rheumatic disease. The enrolled patients were divided into survivors or non-survivors. Information about the demographics, clinical manifestations, CT scan features, laboratory findings and outcomes were collected from their medical records. A least absolute shrinkage and selection operator regularized Cox regression model was used to select the most relevant factors. Prognosis was analysed using a Kaplan-Meier curve. A Cox proportional hazards model was used to identify independent predictive factors for long-term survival.

RESULTS

A total of 62 patients (26 women) with DM-associated PnM were enrolled. The mean age was 44.3 years (s.d. 11.7). The median follow-up duration was 17 days (quartiles 7, 266.5). Thirty-five patients died during follow-up. The survival rates were 75.4% at 1 week, 46.2% at 3 months and 41.9% at 1 year. The Cox proportional hazards model identified the development of fever [hazard ratio (HR) 3.23 (95% CI 1.25, 8.35), P = 0.02] and a decrease in the number of lymphocytes [HR 2.19 (95% CI 1.10, 4.39), P = 0.03] as independent risk factors for death.

CONCLUSION

The results suggest poor overall survival among patients with DM-associated PnM. Survival during the first 3 months is crucial for long-term survival. Meanwhile, the development of fever and a decrease in the number of lymphocytes were associated with long-term mortality. Early recognition and prompt treatment of this high-risk group of DM patients is therefore important.

A composite risk model predicts disease progression in early stages of COVID-19: A propensity score-matched cohort study

Background

Recently, studies on COVID-19 have focused on the epidemiology of the disease and clinical characteristics of patients, as well as on the risk factors associated with mortality during hospitalization in critical COVID-19 cases. However, few research has been performed on the prediction of disease progression in particular group of patients in the early stages of COVID-19.

Methods

The study included 338 patients with COVID-19 treated at two hospitals in Wuhan, China, from December 2019 to March 2020. Predictors of the progression of COVID-19 from mild to severe stages were selected by the logistic regression analysis.

Results

COVID-19 progression to severe and critical stages was confirmed in 78 (23.1%) patients. The average value of the neutrophil-to-lymphocyte ratio (NLR) was higher in patients in the disease progression group than in the improvement group. Multivariable logistic regression analysis revealed that elevated NLR, LDH and IL-10 were independent predictors of disease progression. The optimal cut-off value of NLR was 3.75. The values of the area under the curve, reflecting the accuracy of predicting COVID-19 progression by NLR was 0.739 (95%CI: 0.605–0.804). The risk model based on NLR, LDH and IL-10 had the highest area under the ROC curve.

Conclusions

The performed analysis demonstrates that high concentrations of NLR, LDH and IL-10 were independent risk factors for predicting disease progression in patients at the early stage of COVID-19. The risk model combined with NLR, LDH and IL-10 improved the accuracy of the prediction of disease progression in patients in the early stages of COVID-19.

Efficacy of plasma exchange in anti-MDA5-positive dermatomyositis with interstitial lung disease under combined immunosuppressive treatment

OBJECTIVES

Rapidly progressive interstitial lung disease (RP-ILD) with poor prognosis often accompanies anti-melanoma differentiation-associated gene 5 (MDA5)-positive DM. Combined immunosuppressive therapy, including glucocorticoids, calcineurin inhibitors and intravenous cyclophosphamide (IVCY) is reportedly effective in DM with RP-ILD, but some patients remain resistant to therapy. We examined the utility of plasma exchange (PE) in such intractable cases and investigated the prognostic factors of the disease.

METHODS

Thirty-eight anti-MDA5-positive DM-ILD patients who received the combined immunosuppressive therapy were retrospectively reviewed. Their serum cytokines were evaluated by multiplex assay before treatment. The patients were divided into two groups: those who achieved remission without exacerbation of respiratory dysfunction (n = 25, group A) and those who progressed to hypoxemia during the treatment (n = 13, group B).

RESULTS

PE was carried out in eight group B patients, but none of group A. Five of the eight treated with PE survived, while the five untreated patients died (P =0.04). Higher neutrophil lymphocyte ratio, higher serum ferritin, hypoxemia, high-resolution computed tomography (HRCT) score before treatment and increase of Krebs von Lungen-6 (KL-6) in the first 4 weeks of the treatment were the prognostic factors for disease progression. Serum cytokines such as IL-1, IL-6, IL-8, IL-10, IL-12p70, IL-18 and sCD163 levels were higher in group B than group A.

CONCLUSION

PE should be an effective adjuvant treatment in anti-MDA5-positive DM with RP-ILD. Assessment of basal laboratory tests or monocyte/macrophage-derived cytokines and the increase of KL-6, HRCT score and hypoxemia may help us to predict intractable cases and to make early treatment decisions regarding PE in anti-MDA5-positive DM.

Prognostic value of peripheral blood markers in patients with myositis-associated interstitial lung diseases

Objectives: The aim of this study was to investigate the association between survival of anti-MDA5 autoantibody-positive/negative patients with myositis-associated interstitial lung disease (MA-ILD) and neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), C-reactive protein-albumin ratio (CAR), and erythrocyte sedimentation rate-albumin ratio (EAR).Method: The study included 104 patients diagnosed with MA-ILD between January 2017 and February 2019 at the First Affiliated Hospital, University of Science and Technology of China. The clinical and laboratory results were compared between survivors and non-survivors in anti-MDA5 autoantibody-positive and anti-MDA5 autoantibody-negative patients. Cox proportional hazard models were used for univariable and multivariate analyses to determine survival-related factors. A logistic regression model was used to establish a joint diagnosis, and the feasibility of the combined diagnosis to evaluate the prognosis of MA-ILD was explored.Results: Among 47 anti-MDA5-positive patients with MA-ILD, EAR was an independent predictor of survival. When separated into high and low subgroups, high MLR (> 0.604) and EAR (> 1.458) were predictive of survival (p < 0.05). High MLR, high EAR, and age combined with lactate dehydrogenase were the highest (0.886) in predicting the prognosis of MA-ILD, and were higher than the area under the curve diagnosed separately. In 57 anti-MDA5-negative patients with MA-ILD, NLR and high EAR (> 0.872) were independent predictors of survival (p < 0.05).Conclusion: MLR and EAR are associated with prognosis in anti-MDA5-positive patients. NLR and EAR are associated with prognosis in anti-MDA5-negative patients. Using NLR, MLR, and EAR, inflammatory conditions of MA-ILD can be predicted and possible outcomes estimated.

Characteristics and outcomes of overlap myositis: a comparative multigroup cohort study in adults from the MyoCite cohort

Overlap myositis (OM), an important subset of idiopathic inflammatory myopathies (IIM), is being increasingly recognized with wider myositis-specific autoantibody (MSA) testing. We studied the differences in clinical characteristics and long-term outcomes of OM with Dermatomyositis (DM), Polymyositis (PM), anti-synthetase syndrome (ASSD), and Cancer-associated IIM (CAM). Data from the MyoCite registry (Dec2017-May2020), a prospective dataset of IIM was extracted for the clinical profile, and MSAs, immunosuppressants received, disease activity (relapses and incomplete response), and treatment-related (drugs ADRs and infections) adverse events (DRAE and TRAE) were collected and analyzed between groups. Of 214 adults (58-OM,89-DM,27-ASSD,33-PM,7-CAM), OM had a greater female preponderance (13.5:1). Raynaud's and sclerodactyly were the prime distinguishing features of OM. OM could be distinguished from PM by frequent arthritis (OR-3.2) and infrequent dysphagia (OR-0.17); DM with greater nephritis (OR-20), infrequent dysphagia (OR-0.24) and rashes (OR-0.02); and ASSD by infrequent ILD (OR-0.07), and mechanic's hand (OR-0.05). 50% fulfilled the classification criteria for ASSD in the absence of MSA testing. ANA was positive more often (PM/DM: OR-6.7) and anti-Ro52 (OR-4.5) frequent in OM. Baseline serum creatinine and acute phase reactants were higher. OM received lower glucocorticoids (0 mg/kg, p < 0.001). Overall, 90% and 84% of OM at 12 and 24 months, respectively, achieved remission, with similar DRAE and TRAE as other IIM subsets. OM can be misdiagnosed as ASSD in the absence of MSA testing. Raynaud's, sclerodactyly, and a positive ANA may identify OM and prevent overtreatment.

Prevalence of interstitial lung disease in polymyositis and dermatomyositis: A meta-analysis from 2000 to 2020

OBJECTIVE

Interstitial lung disease (ILD) is the most important prognostic factor for mortality in patients with polymyositis (PM) and dermatomyositis (DM), but the prevalence of ILD in PM/DM may vary between countries. The aim of this study was to determine the overall prevalence of ILD in global patients with PM/DM.

METHODS

We performed a systematic literature review of studies published from Jan 1, 2000 to April 30, 2020 on ILD and PM/DM. We extracted data and pooled the prevalence by using a random-effect model due to high heterogeneity. Heterogeneity was assessed by subgroup analysis and sensitivity analysis.

RESULTS

A total of 34 studies with 10,130 patients were included in our meta-analysis. Pooled data demonstrated that the global prevalence of ILD in patients with PM/DM was 0.41 (95% confidence interval [CI] 0.35-0.48). However, this prevalence varied with geographical locations and time trends. The prevalence of ILD in PM/DM was 0.5 (95% CI 0.42-0.57) in Asia, 0.23 (95% CI 0.15-0.31) in America, and 0.26 (95% CI 0.18-0.34) in Europe. A higher prevalence of ILD was reported in studies published in 2011-2015 (0.43, 95% CI 0.34-0.52) and 2016-2020 (0.45, 95% CI 0.35-0.54), compared with those published in 2000-2010 (0.27, 95% CI 0.16-0.39). The pooled prevalence of ILD in patients with DM, PM, and clinically amyopathic dermatomyositis subtype was 0.42 (95% CI 0.35-0.49), 0.35 (95% CI 0.27-0.42), and 0.53 (95% CI 0.32-0.74), respectively. Patients with anti-Jo-1 and anti-melanoma differentiation-associated gene 5 antibodies were more likely to develop ILD than other myositis-specific autoantibodies.

CONCLUSION

The global prevalence of ILD in patients with PM/DM was approximately 41% and the condition was predominant in Asians. This highlights potential genetic and environmental differences in the pathogenesis of ILD in patients with PM/DM. More studies are required to elucidate the specific associations.

Risk factors for progression and prognosis of primary Sjögren's syndrome-associated interstitial lung disease in a Chinese population

OBJECTIVE

This study explored differences between primary Sjögren's syndrome-associated interstitial lung disease (pSS-ILD) patients with and without ILD progression, and analyzed the factors affecting the progression and prognosis of pSS-ILD.

METHODS

This study is a retrospective cohort study which enrolled 113 pSS-ILD patients hospitalized between 2011 and 2017.

RESULTS

The 3-year survival rate of the pSS-ILD patients was 91.15%, and the 5-year survival rate was 84.07%. Univariate analysis showed that Raynaud's syndrome, hypoproteinemia, extensive lung involvement, possible usual interstitial pneumonia pattern were risk factors for the progression of ILD in patients with pSS-ILD, and cyclophosphamide was a protective factor for the progression of ILD in patients with pSS-ILD. Multiple logistic regression analysis showed that extensive lung involvement (odds ratio 4.143, 95% CI: 1.203-14.267, P < .05) was an independent risk factor for the progression of pSS-ILD. Cox hazard analysis showed that pSS-ILD with hypoproteinemia (hazard ratio [HR] 17.758, 95% CI: 4.753-66.340, P <- .05) and extensive lung involvement (HR 3.450, 95% CI: 1.419-8.390, P < .05) were associated with worse survival of patients.

CONCLUSION

Extensive lung involvement is an independent risk factor for the progression of ILD in patients with pSS-ILD. Hypoproteinemia and extensive lung involvement are independent risk factors for mortality in patients with pSS-ILD, after controlling for potentially influential variables.

Malignancy in dermatomyositis: A retrospective paired case-control study of 202 patients from Central China

Dermatomyositis (DM) is an idiopathic inflammatory myopathy that is closely related to malignant diseases. Our study aims to investigate the incidence and predictive factors for occurrence of malignancy among DM patients from Central China.We performed a retrospective, paired, case-control study of 736 DM patients admitted to the First Affiliated Hospital of Zhengzhou University between 2010 and 2017. We paired the 65 patients with malignancy with age-matched and sex-matched patients without malignancy in a ratio of 1:2. Two hundred two patients were finally enrolled and their clinical and laboratory data were collected.The incidence of malignancy in DM patients was 8.83% (65/736). Most malignancies were detected in the most recent 1 year before (9/65, 13.85%) or within 3 years after (40/65, 61.54%) the onset of DM. Males (35/65, 53.85%) and patients aged between 50 and 69 years (43/65, 66.15%) were prone to develop malignancies. Lung cancer (n = 11, 31.43%) was the most common malignancy in male patients, while for females, thyroid, breast and cervical cancer (n = 4 each, 13.33%) were more prevalent. Adenocarcinoma and squamous cell carcinoma (both 18/65, 27.69%) were the top two most common pathological types. Univariate analysis demonstrated that Gottron's sign (P = .02), dysphagia (P = .04), albumin (ALB) reduction (P = .003), aspartate aminotransferase (AST, P = .03), creatine kinase-MB (P = .02), absence of fever (P = .02), arthralgia (P = .04) and interstitial lung disease (ILD, P = .05) were closely related to the occurrence of malignancy. Multivariate analysis revealed the independent risk factors of ALB reduction (odds ratio = 1.546, P = .04) and the protective factor of ILD (odds ratio = 0.349, P = .003). There was no significant difference in the follow-up period between patients with and without ILD (P = .38).ALB reduction and the absence of ILD were the risk factors for malignancy in DM patients. The protective mechanism of ILD for DM patients needs further study.

Neutrophil-To-Lymphocyte Ratio and Systemic Immune-Inflammation Index-Biomarkers in Interstitial Lung Disease

Background and objectives: The aims of the study were to evaluate the utility of neutrophil-to-lymphocyte ratio (NLR) and the systemic immune-inflammation index (SII) as inflammation markers and prognostic factors in patients with known interstitial lung disease secondary to connective tissue diseases (CTD-ILD) compared with idiopathic pulmonary fibrosis (IPF). Materials and Methods: Forty-two patients with known interstitial lung disease (21 with IPF and 21 with CTD-ILD) and 42 control matched healthy patients were included. The NLR was calculated as the absolute neutrophil count divided by the absolute lymphocyte count, and the SII was calculated as follows: SII = platelets × neutrophils/lymphocytes, with the data being obtained from the patients data charts at admission, before any treatment. Results: our hypothesis was that in patients with interstitial lung disease NLR and SII would have higher values compared with patients with CTD-ILD or control healthy patients. The mean NLR value was 3.01 (±1.35) among patients with idiopathic pulmonary fibrosis, and 2.38 (±1.08) among patients with CTD-ILD without significant statistical difference (p = 0.92). There was however a clinically significant statistical difference when compared with the control group, where NLR was 2.00 (±1.05) (p = 0.003). SII values were 619.37 (±329.51) in patients with IPF, 671.55 (±365.73) in CTD-ILD group and 569.73 (±326.67) in healthy subjects (p = 0.13) Conclusions: A mean NLR value of 2.8 and a SII value over 500 in patients with connective diseases can become a marker of pulmonary interstitial involvement. In the context of non-exacerbated interstitial lung disease, NLR and SII have reduced numerical values, without being statistically correlated with prognosis when we compared with patients with connective tissue diseases without exacerbation or with healthy people, the cut off being of 2.4. However subsequent studies in larger patient samples might provide changes in these cut-off values.

Immunopathology of SARS-CoV-2 Infection: Immune Cells and Mediators, Prognostic Factors, and Immune-Therapeutic Implications

The present is a comprehensive review of the immunopathology of Covid-19. The immune reaction to SARS-CoV-2 infection is characterized by differentiation and proliferation of a variety of immune cells with immune mediator production and release, and activation of other pathogen resistance mechanisms. We fully address the humoral and cellular immune changes induced by the virus, with particular emphasis on the role of the “cytokine storm” in the evolution of the disease. Moreover, we also propose some immune alterations (i.e., inflammatory parameters, cytokines, leukocytes and lymphocyte subpopulations) as prognostic markers of the disease. Furthermore, we discuss how immune modifying drugs, such as tocilizumab, chloroquine, glucocorticoids and immunoglobulins, and blood purification therapy, can constitute a fundamental moment in the therapy of the infection. Finally, we made a critical analysis of a number of substances, not yet utilized, but potentially useful in SARS-CoV-2 patients, such as IFN lambda, TNF blockers, ulinastatin, siponimod, tacrolimus, mesenchymal stem cells, inhibitors of mononuclear macrophage recruitment, IL-1 family antagonists, JAK-2 or STAT-3 inhibitors.

Neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with COVID-19

Background

Several studies have described the clinical characteristics of patients with novel coronavirus (SARS-CoV-2) infected pneumonia (COVID-19), indicating severe patients tended to have higher neutrophil to lymphocyte ratio (NLR). Whether baseline NLR could be an independent predictor of in-hospital death in Chinese COVID-19 patients remains to be investigated.

Methods

A cohort of patients with COVID-19 admitted to the Zhongnan Hospital of Wuhan University from January 1 to February 29 was retrospectively analyzed. The baseline data of laboratory examinations, including NLR, were collected. Univariate and multivariate logistic regression models were developed to assess the independent relationship between the baseline NLR and in-hospital all-cause death. A sensitivity analysis was performed by converting NLR from a continuous variable to a categorical variable according to tertile. Interaction and stratified analyses were conducted as well.

Results

245 COVID-19 patients were included in the final analyses, and the in-hospital mortality was 13.47%. Multivariate analysis demonstrated that there was 8% higher risk of in-hospital mortality for each unit increase in NLR (Odds ratio [OR] = 1.08; 95% confidence interval [95% CI], 1.01 to 1.14; P = 0.0147). Compared with patients in the lowest tertile, the NLR of patients in the highest tertile had a 15.04-fold higher risk of death (OR = 16.04; 95% CI, 1.14 to 224.95; P = 0.0395) after adjustment for potential confounders. Notably, the fully adjusted OR for mortality was 1.10 in males for each unit increase of NLR (OR = 1.10; 95% CI, 1.02 to 1.19; P = 0.016).

Conclusions

NLR is an independent risk factor of the in-hospital mortality for COVID-19 patients especially for male. Assessment of NLR may help identify high risk individuals with COVID-19.

Fluid Biomarkers for Predicting the Prognosis of Liver Cirrhosis

Liver cirrhosis is the terminal stage of most chronic liver conditions, with a high risk of mortality. Careful evaluation of the prognosis of cirrhotic patients and providing precise management are crucial to reduce the risk of mortality. Although the liver biopsy and hepatic venous pressure gradient (HVPG) can efficiently evaluate the prognosis of cirrhotic patients, their application is limited due to the invasion procedures. Child-Pugh score and the model for end-stage liver disease (MELD) score had been widely used in the assessment of cirrhotic prognosis, but the defects of subjective variable application in Child-Pugh score and unsuitability to all phases of liver cirrhosis in MELD score limit their prognostic values. In recent years, continuous efforts have been made to investigate the prognostic value of body fluid biomarkers for cirrhotic patients, and promising results have been reported. Since the collection of fluid specimens is easy, noninvasive, and repeatable, fluid biomarkers can be ideal indicators to predict the prognosis of cirrhosis. Here, we reviewed noninvasive fluid biomarkers in different prognostic functions, including the prediction of survival and complication development.

Neutrophil dysregulation is pathogenic in idiopathic inflammatory myopathies

Idiopathic inflammatory myopathies (IIM) are characterized by muscle inflammation and weakness, myositis-specific autoantibodies (MSAs), and extramuscular organ damage. The role of neutrophil dysregulation and neutrophil extracellular traps (NETs) in IIM is unclear. We assessed whether pathogenic neutrophil subsets (low-density granulocytes [LDGs]) and NETs were elevated in IIM, associated with clinical presentation and MSAs, and their effect on skeletal myoblasts and myotubes. Circulating NETs and LDGs were quantified and correlated with clinical measures. Specific MSAs were tested for their ability to induce NETs. NETs and neutrophil gene expression were measured in IIM biopsies. Whether NETs damage skeletal myoblasts and myotubes was tested. Circulating LDGs and NETs were increased in IIM. IIM LDGs had an enhanced ability to form NETs. LDGs and NETs correlated with IIM disease activity and muscle damage. The serum MSA anti-MDA5 correlated with circulating and tissue NETs and directly enhanced NET formation. An enhanced neutrophil gene signature was present in IIM muscle and associated with muscle injury and tissue IFN gene signatures. IIM NETs decreased the viability of myotubes in a citrullinated histone-dependent manner. Dysregulated neutrophil pathways may play pathogenic roles in IIM through their ability to directly injure muscle cells and other affected tissues.

New treatment paradigms for connective tissue disease-associated interstitial lung disease

PURPOSE OF REVIEW

Interstitial lung disease (ILD) is frequently observed in connective tissue disease (CTD) and is a major cause of mortality. In CTD-ILD, a marked variability in morphological patterns, time course and severity exists. In many patients, CTD-ILD is limited and inherently stable, although a significant proportion of patients have progressive disease. We review the utility of integration of the recently proposed disease behavior classification into the management of CTD-ILD, and recent advances in treatment approaches.

RECENT FINDINGS

Recent studies on scleroderma-ILD (SSc-ILD) staging and short-term lung function trends provide important information, although accurate prognostic markers, particularly in limited/early CTD-ILD, are still needed. Most patients with progressive CTD-ILD stabilize on immunosuppression, as observed in recent SSc-ILD trials and CTD-ILD retrospective series. A minority of patients present with life-threatening acute/subacute ILD, requiring intense immunosuppression, with limited available guidance. A significant minority of CTD-ILD patients have progressive disease despite immunosuppression. Ongoing trials with antifibrotic agents and with biologic agents may reveal a potential role for their use/addition.

SUMMARY

Ultimately, further research into the mechanisms linking autoimmunity to fibrosis and randomized controlled clinical trials are needed, with the aim of preventing irreversible damage of lung tissue, while minimizing burden of treatment.

Biomarkers in Adult Dermatomyositis: Tools to Help the Diagnosis and Predict the Clinical Outcome

Dermatomyositis pathophysiology is complex. In recent years, medical research has identified molecules associated with disease activity. Besides providing insights into the driving mechanisms of dermatomyositis, these findings could provide potential biomarkers. Activity markers can be used to monitor disease activity in clinical trials and may also be useful in daily practice. This article reviews molecules that could be used as biomarkers for diagnosis and monitoring dermatomyositis disease activity.

Tumor-Infiltrating T Cell Receptor-Beta Repertoires are Linked to the Risk of Late Chemoradiation-Induced Temporal Lobe Necrosis in Locally Advanced Nasopharyngeal Carcinoma

PURPOSE

Temporal lobe necrosis (TLN), a late complication of nasopharyngeal carcinoma (NPC) after concurrent chemoradiotherapy (CCRT), causes permanent neurologic deficits. We aimed to investigate the risk factors for the development of CCRT-induced TLN in locally advanced NPC patients.

METHODS AND MATERIALS

The incidence of CCRT-induced TLN was assessed in consecutive patients with NPC initially staged with T_3-4N_0-3M₀ receiving curative intensity modulated radiation therapy (IMRT) and cisplatin-based chemotherapy with long-term follow-up. The TLN risk was evaluated with radiation dose-volume histograms (a dosimetric risk indicator of organ injury) and the dynamics of blood circulating neutrophil-to-lymphocyte ratios (a clinical indicator of systemic inflammation) by linear and logistic regression models. High-throughput unbiased T cell receptor-beta (TCR_beta) sequencing was performed to correlate the different TCR_beta repertoires of NPC-infiltrating lymphocytes (a biological factor of the immune microenvironment) with TLN incidence.

RESULTS

In the era of modern IMRT-based CCRT, radiation doses of up to 74 Gy achieved local control rates of more than 90% in both T₃ and T₄ diseases but still induced a remarkably higher incidence of TLN in the T₄ patients (30.14%) compared with the rare incidence of TLN observed in the T₃ patients (2.78%) (P < .0001). We found that in the T₄ NPC patients, univariate and multivariate analyses showed the radiation tolerance dose-volume effect was not an absolutely independent factor influencing TLN occurrence. However, increased TLN risk was observed in association with higher pre-CCRT baseline and post-CCRT neutrophil-to-lymphocyte ratios. There was also a link between intratumoral TCR_beta repertoire subtypes and TLN incidence. Combining the inherent TCR_beta genomic susceptibility with the clinical variable neutrophil-to-lymphocyte ratio better predicted the risk of TLN for T₄ NPC patients after CCRT.

CONCLUSIONS

The associations of tumor-infiltrating lymphocyte repertoires and blood circulating neutrophil-to-lymphocyte ratios with TLN occurrence in T₄ NPC patients suggest that the immune and inflammatory milieus play roles in the late brain damage caused by CCRT. Modulated or provoked by CCRT locally and systemically, the reciprocal interactions of neutrophils and lymphocytes in the intracranial NPC-associated immune microenvironment could be a key driver of chronic TLN pathogenesis.

Neutrophil-to-Lymphocyte Ratio Associates Independently With Mortality in Hospitalized Patients With Cirrhosis

BACKGROUND & AIMS

The neutrophil to lymphocyte ratio (NLR) is a biomarker of immune dysregulation in patients with cirrhosis and is inexpensive to measure. We investigated the association between NLR and mortality in hospitalized patients with cirrhosis at 4 liver transplant centers, controlling for severity of acute-on-chronic liver failure (ACLF).

METHODS

We performed a retrospective study using data from the North American Consortium for the Study of End-stage Liver Disease on patients with index hospitalizations for cirrhosis from December 2011 through December 2016. We collected data on patient demographics, NLR, model for end-stage liver disease (MELD) scores, serum levels of Na, cirrhosis stages, infections, hepatocellular carcinomas, and ACLF severity (based on number of organ failures). Competing risk regression analysis evaluated mortality within 1 year after hospital discharge, accounting for competing events (liver transplant).

RESULTS

At admission, the patients' mean age was 57 years, mean MELD score was 21, and mean serum level of Na was 134 mmol/L. Sixty-eight patients had no organ failure, 21 patients had 1 organ failures, 7 patients had 2 organ failures, 4 patients had 3 organ failures, and 1 patient had 4 organ failures; 36% of the patients had confirmed or suspected infections. In univariate models, risk of death associated with increasing NLR, up to a value of 8 (hazard ratio [HR]= 1.14; 95% CI, 1.07-1.20; P < .001), and NLR quartile (for NLR range of 3-5, HR = 2.17; for NLR range of >5-9, HR=2.46; for NLR quartile >9, HR=2.84 vs the lowest quartile [NLR<3]) (P ≤ .001). The NLR remained statistically significant in multivariable models, adjusting for age, MELD score, hepatocellular carcinoma, and ACLF severity. Additionally, NLR was a statistically significant independent predictor of length of index hospital stay and mortality within 90 days after discharge.

CONCLUSION

In a retrospective analysis of patients with cirrhosis, we found NLR to associate with death within 1 year after non-elective hospitalization. In these patients, the risk of death associated with acute immune dysregulation persists long after their initial hospitalization.