ABSTRACT
Background: There is a paucity of data in the literature about the outcome of patients with idiopathic infammatory myopathy (IIM) who have been infected with SARS-CoV-2. Objectives: To investigate factors associated with severe COVID-19 outcomes in patients with IIM. Methods: Data on demographics, number of comorbidities, region, COVID-19 time period, physician-reported disease activity, anti-rheumatic medication exposure at the clinical onset of COVID-19, and COVID-19 outcomes of IIM patients were obtained from the voluntary COVID-19 Global Rheumatology Alliance physician-reported registry of adults with rheumatic disease (from 17 March 2020 to 27 August 2021). An ordinal COVID-19 severity scale was used as primary outcome of interest, with each outcome category being mutually exclusive from the other:a) no hospital-ization, b) hospitalization (and no death), or c) death. Odds ratios (OR) were estimated using multivariable ordinal logistic regression. In ordinal logistic regression, the effect size of a categorical predictor can be interpreted as the odds of being one level higher on the ordinal COVID-19 severity scale than the reference category. Results: Complete hospitalization and death outcome data was available in 348 IIM cases. Mean age was 53 years, and 223 (64.1%) were female. Overall, 167/348 (48.0%) people were not hospitalized, 136/348 (39.1%) were hospitalized (and did not die), and 45/348 (12.9%) died. Older age (OR=1.59 per decade of life, 95%CI 1.32-1.93), male sex (OR=1.63, 95%CI 1.004-2.64;versus female), high disease activity (OR=4.05, 95%CI 1.29-12.76;versus remission), presence of two or more comorbidities (OR=2.39, 95%CI 1.22-4.68;versus none), predni-solone-equivalent dose >7.5 mg/day (OR=2.37, 95%CI 1.27-4.44;versus no gluco-corticoid intake), and exposure to rituximab (OR=2.60, 95%CI 1.23-5.47;versus csDMARDs only) were associated with worse COVID-19 outcomes (Table 1). Conclusion: These are the frst global registry data on the impact of COVID-19 on IIM patients. Older age, male gender, higher comorbidity burden, higher disease activity, higher glucocorticoid intake and rituximab exposure were associated with worse outcomes. These fndings will inform risk stratifcation and management decisions for IIM patients.
ABSTRACT
Background: The COVID-19 pandemic has disrupted healthcare delivery and education of physicians, including rheumatology trainees. Objectives: To assess the impact of the COVID-19 pandemic on the clinical experiences, research opportunities, and well-being of rheumatology trainees. Methods: A voluntary, anonymous, web-based survey was administered in English, Spanish, or French from 19/08/2020 to 05/10/2020. Adult and paediatric rheumatology trainees worldwide in training in 2020 were invited to participate via social media and email. Using multiple choice questions, Likert scales, and free text answers, we assessed trainee patient care activities, redeployment, research, and well-being. Results: The 302 respondents were from 33 countries, with most (83%, 252/302) in adult rheumatology training. Many trainees (45%, 135/300) reported an increase in non-rheumatology clinical work (e.g. care of COVID-19 patients), with 52% of these (70/135) also continuing rheumatology clinical work. COVID-19 redeployment was not optional for 68% (91/134). Trainees reported a negative impact of the pandemic in their growth in rheumatology (Figure 1). They also reported a substantial impact on several training areas: outpatient clinics (79%, 238/302), inpatient consultations (59%, 177/302), formal teaching (55%, 167/302), procedures (53%, 147/302), teaching opportunities (52%, 157/302), and ultrasonography (36%, 110/302), with 87-96% perceiving a negative impact on these areas. Only 54% (159/294) reported feeling comfortable with their level of clinical supervision during the pandemic (Figure 1). Many trainees (46%, 128/280) reported changes in research experiences during the pandemic;39% (110/285) reported that COVID-19 negatively affected their ability to continue their pre-pandemic research and 50% (142/285) reported difficulty maintaining research goals (Figure 1). Some rheumatology trainees reported having health condition(s) putting them at high risk for COVID-19 (10%, 30/302) and 14% of trainees (41/302) reported having had COVID-19 (Table 1). Only 53% (160/302) reported feeling physically safe in the workplace while 25% (76/302) reported not feeling physically safe;reasons included lack of training about COVID-19, lack of comfort in the clinical setting, insufficient personal protective equipment, immunocompromised state, and pregnancy. Half (151/302) reported burnout and 68% (204/302) an increase in stress from work during the pandemic (Figure 1), whilst 25% (75/302) reported that changes to their training programme negatively impacted their physical health. Conclusion: The COVID-19 pandemic has negatively impacted the experience of rheumatology training as well as the well-being of trainees globally. Our data highlight concerns for rheumatology trainees including research opportunities and clinical care which should be a focus for curriculum planning.
ABSTRACT
Background: The COVID-19 pandemic led to a rapid increase in remote consultations in rheumatology care. Due to the potential impact of this change on rheumatology clinical training, we investigated trainees' experiences with telemedicine. Objectives: To assess the impact of telemedicine use during the COVID-19 pandemic on rheumatology training, including supervision. Methods: A voluntary, anonymous web-based survey was administered in English, Spanish, or French from 19/08/2020 to 05/10/2020. Adult and paediatric rheumatology trainees worldwide in training in 2020 were invited to participate via social media and email. Using multiple choice questions, Likert scales, and free text answers, we collected data regarding prior and current telemedicine use, training, and supervision. Results: 302 respondents from 33 countries completed the survey, with most (83%, 252/302) in adult rheumatology training. Reported use of telemedicine increased from 13% (39/302) pre-pandemic to 82% (247/302) (Table 1). European trainees predominantly utilised audio-only compared to trainees from the rest of the world (ROW) who predominantly utilised audio-video telemedicine. Most trainees continued to evaluate new patients using telemedicine (65%, 161/247). A larger proportion of trainees were comfortable using telemedicine to evaluate follow-up (69% 170/247) versus new patients (25%, 41/161) (Figure 1). Only 32% (97/302) were trained in telemedicine, with the highest proportion among United States (US) trainees (59%, 69/116);subjects included software, clinical skills, and billing. The majority of trainees found this helpful (92%, 89/97). Supervision was most frequently in the form of verbal discussion after the consultation (Table 1);24% (59/247) had no telemedicine supervision during the pandemic. In general, trainees found telemedicine negatively impacted their supervision (51%, 123/242) and clinical teaching quality (70%, 171/244);only 9% reported a positive impact on these areas. Conclusion: Adoption of telemedicine during the COVID-19 pandemic has led to areas of concern for rheumatology trainees including inadequate supervision and clinical teaching. Our results suggest a need for education on evaluation of new patients using telemedicine, increasing telemedicine training, and ensuring adequate supervisory arrangements.
ABSTRACT
Background/AimsPatient and public involvement (PPI) initiatives are important to ensurepatient-centered research. However, traditional focus groups canpresent challenges including the recruitment and retention of patientpartners. Additional challenges to patient involvement have also arisendue to the coronavirus pandemic (COVID-19). The University CollegeLondon (UCL) Patient Partners in Rheumatology Research initiativehas been developed to explore novel ways to boost patientinvolvement and foster an active collaboration between basicresearchers and patient partners.MethodsTwo online surveys were designed to obtain information with regardsto the expectations and practicalities of this initiative. One survey wassent to patients who had registered an interest in being patientpartners and the other survey to rheumatology researchers at UCL andUniversity College London Hospital (UCLH).ResultsWe received responses from 25 researchers and 21 patients. Themajority of patients who responded (71%) had not previously beeninvolved in PPI. Most of the researchers (84%) had previously utilisedPPI, however 20% of those had some difficulty accessing it.Most patients (86%) were interested in becoming a patient partner.Amongst those with reservations, one stated that ''I don't think I havethe qualifications to be involved with scientists and researchers''. Overhalf of patients (52%) were happy to participate in PPI more than fivetimes a year and most researchers (84%) expressed that five times ayear was acceptable. Patients favoured (52%) conducting PPI meetings after office hours (5-8pm) during the working week. Due to socialrestrictions because of COVID-19, we asked both patients andresearchers their preferred mode of meeting. Both groups favoureda mixed (virtual and face to face) meeting arrangement (81% forpatients and 68% for researchers). A third of patients (38%) expressedthat they would need technical assistance accessing a virtual meeting.Almost all patients (95%) were happy to contribute to lay summaryreviews remotely via email.ConclusionBased on the insights gained from the survey results, our PPI initiativemeetings will be hosted in a hybrid virtual/face to face format. Thesewill be held at a time and frequency that is convenient for the patientpartners to increase participation across wider demographics. Thissurvey has highlighted that we have to be mindful of certain patientperceptions of PPI which creates a barrier to patient involvement andthat some individuals may require further support in accessing virtualmeetings. By designing a PPI initiative that creatively addressed theneeds of both the researchers and patient partners we hope to createa platform for productive dialogue and collaboration to ensure patientcentred research, despite the changes brought about by the COVID-19 pandemic.
ABSTRACT
Background/AimsRheumatologists are facing a significant challenge in the managementof early rheumatoid arthritis (RA) due to limitations placed onoutpatient visits during the COVID-19 pandemic. Frequent clinicalassessments of disease activity are recommended during implementation of the treat to target strategy to achieve remission. A biomarkerindicating response to methotrexate during the early phase of therapycould complement clinical examination. Methotrexate increaseserythrocyte mean corpuscular volume (MCV), which is measuredroutinely, prompting us to investigate whether changes in MCV couldact as an early indicator of response.MethodsPatients with early RA who were started on methotrexate therapy wereincluded from two independent cohorts. The larger cohort (discoverycohort, n = 655) was used to build the model and the second cohort(validation cohort, n = 225) was applied to test the prediction of themodel. Conventional statistical, and machine learning approacheswere adopted to identify key determinants that influence the potentialrelationship between MCV and clinical response, defined as attainment of remission or low disease activity, at six months after startingmethotrexate. ResultsA LASSO penalised logistic regression model was built with thediscovery cohort [area under the receiver operating characteristics(AUROC) curve = 0.76], where change of MCV from three months[Odds ratio (OR) 1.53 (95% CI 1.38-1.70)], concomitant use ofhydroxychloroquine [OR 2.16 (95% CI 1.52 - 3.07, p < 0.001)], andseropositivity [OR 1.83 (95% CI 1.12 - 3.03, p = 0.02)] were associatedwith favourable methotrexate response [accuracy 81% (95% CI 76%-86%) of the model testing against discovery model]. Different machinelearning classification methods were applied. Random forest exhibitedthe maximum accuracy and AUROC (89%, and 86%, respectively),confirming the above three predictors as the most significant. Twolatent classes (class 1: smaller MCV increase and class 2: greater MCVincrease) were identified based on the MCV changes over six months.Class 1 had fewer responders and a lower number of patients onhydroxychloroquine compared to class 2. The earliest time point ofsignificant difference of MCV between responders and non-responders was three months [mean difference 1.43 (95% CI 0.57-2.3)].Combination hydroxychloroquine and methotrexate caused the greatest increase in MCV with a difference between responders and nonresponders at 2 months. Change of MCV at three months showedAUROC of 0.75 to predict treatment response to the combination ofmethotrexate and hydroxychloroquine at six months with an optimalcut-point of MCV 3.5 fL (95% CI 3.5-3.6) with 71% sensitivity and75%, specificity.ConclusionOur data provides mechanistic insight into the synergistic clinicalbenefit of concomitant hydroxychloroquine with methotrexate, boosting the rise in erythrocyte MCV which could serve as an earlybiomarker of treatment response.