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Background/Aims Research has shown nurse-led gout clinics provide better outcomes compared to usual care. This District General Hospital set up a pilot nurse-led gout clinic in autumn 2019. This aimed to improve patients' understanding of their condition, achieve better control of serum uric acid levels (SUA), reduce flares and prevent Emergency Department attendances. Methods A modified clinic protocol, closely modelled on BSR guidance was agreed within the department. With consultant supervision, one nurse specialist provided a mix of in-person and telephone appointments. Targets were set aiming for SUA <360mumol/L for most patients and <300mumol/L for those with erosive change or tophi. All patients were offered prophylaxis. Patients required a rheumatologist's diagnosis of gout or crystal confirmation for enrolment. Exclusion criteria were significant renal or hepatic derangement. Within 3 months of the service starting SARS-CoV-2 impacted the operation of healthcare worldwide and led to the closure of routine outpatient clinics in Northern Ireland. A decision was made to switch the gout clinic to run entirely by telephone. Blood testing was facilitated through primary care and phlebotomy hubs. Results Over a 19-month period, 78 patients were treated and audited through this clinic: 69 men and 9 women. Average age was 57, mean SUA 509 mumol/L at referral and 322 mumol/L on discharge. 69 patients received allopurinol and 9 received febuxostat. No patients required uricosuric drugs. All patients were offered and agreed to take prophylaxis with a majority (85.8%) remaining on it for 3-6 months. Patients required a mean of 3.38 appointments prior to discharge from the clinic. The mean dose of urate lowering therapy on discharge was 315.9mg allopurinol and 93.3mg febuxostat. 95% experienced >=2 flares during their enrolment in the clinic with no patients requiring Emergency Department attendance due to gout flare. Conclusion The nurse-led gout clinic was well received by patients and was effective as a telephone service during the pandemic when so many services were stood down. The clinic was able to continue to provide education, deliver effective reductions in uric acid as well as reduce incidence of flares and Emergency Department attendances. Lower doses of urate lowering therapy than expected were needed to achieve target. A small number of patients were discharged prior to enrolment for initial non-engagement which may have been exacerbated by the lack of face-to-face appointments. Our COVID-19 model did struggle with those patients needing an interpreter. In-person initial appointments have since been restarted;however, a greater proportion of reviews will continue to be offered by telephone given the unexpected success of the model. This audit showed that a nurse-led gout clinic can run successfully, even during a pandemic with a significant reliance on telephone consultations.
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Background/Aims In December 2019, a new type of novel coronavirus (COVID-19) was identified in Wuhan, China. The likelihood of developing an autoimmune and/or rheumatic diseases in COVID-19 survivors is high and a serious matter. The acute SARS-CoV-2 infection may unmask previously undiagnosed rheumatic conditions. We aimed to study rheumatic autoimmune disease manifestations diseases following COVID-19 infection survival. Methods The study was an observational case series study. The data collection was carried out in Iraqi Kurdistan region between the 1st of July 2021 and 20th of March 2022. Seventy-five patients were included: the patients who previously had confirmed COVID-19 infection who developed symptoms of rheumatic autoimmune diseases post COVID-19 cure. The study was conducted via a rigorous evaluation by two rheumatologists. Patients were investigated by (ESR (mm/h) and CRP (mg/L), some autoimmune screen panel for suspecting rheumatological disease patients were sent for ANA, anti-CCP (U/ML) and rheumatoid factor (IU/M) L. Then, patients were diagnosed according to the classification criteria for suspected autoimmune diseases and those with exacerbation were evaluated clinically and by laboratory;rheumatoid arthritis by DAS28, systemic lupus erythematosus by C3, C4. Results A total of seventy-five participants post-COVID-19 infection were enrolled in this study. Age of the participants was 47.15 +/-16.18 SD, more of the participants were female (69) out of 75. For most of the patients the ESR were high with p value of 0.012, which was statistically significant. ANA was high titre in SLE patients which was (3.05+/-2.4) and in antiphospholipid syndrome p-value was significant at 0.042, Anti-CCP were positive in RA patients and in those with exacerbation of RA (44+/-10, 31.7+/-5.7 respectively), DAS28 was (4.95+/-0.59) moderate and high disease activity in patients with exacerbations. C3, C4 were low in patients with exacerbation of SLE (0.47+/-0.22, 0.03+/-0.01, respectively). Most of the patients developed symptoms post-COVID-19 between 4-10 weeks (37 participants). Conclusion Rheumatic autoimmune diseases presenting post-COVID-19 survival most commonly were systemic lupus erythematous followed by rheumatoid arthritis. and previous autoimmune diseases presented with exacerbation. (Table Presented).
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Background/Aims Long Rheumatology waiting lists in the UK were further affected by the COVID-19 pandemic;resulting in negative impacts upon the timeliness and efficiency of patient care. The use of Advanced Practitioners within Rheumatology care pathways has been shown to be safe and effective;they can support the Rheumatology workforce and expedite care where patients are appropriately triaged to them. As part of a service provision change in a NHS Trust, an Advanced Practice Physiotherapist (APP) post was funded with the intent to harness these benefits. Initial utilisation of the APP appointments within the Rheumatology provision was found to be low and could be improved. A Quality Improvement (QI) Project was initiated, with the aim to increase APP appointment utilisation to at least 85% over a period of four months, and for at least 75% of these appointments to contain patients who had been appropriately triaged. Methods The 'Model for Improvement' was chosen as the QI approach. The project was led by an APP. Firstly, a stakeholder analysis was performed to identify staff with influence and interest in the project. A root cause analysis found lack of awareness of triaging clinicians and challenges with booking processes as potential reasons for lowerthan- expected appointment utilisation. Change interventions were devised and tested over three Plan, Do, Study, Act (PDSA) cycles. PDSA one developed communication with booking and triage staff to clarify these processes with them. PDSA two educated clinical staff about the APP role, triage criteria and the booking procedures confirmed in PDSA one. PDSA three focused upon sustaining change by reinforcement of the topics established in PDSA two among staff. Outcome measures used were the percentage of available APP appointments utilised per week, and the percentage of these which contained patients who were appropriately triaged. Results APP appointment utilisation increased from a mean of 22% pre-project to 61% during the change intervention period. Sixty-three patients were seen over the 17-week change intervention period;of which 86% had been appropriately triaged. Data showed that 70% of the patients directed to the APP were managed by them (24% discharged and 46% reviewed). Of the remaining patients, 13% were followed up by a Rheumatologist, 12% did not attend and 5% had an alternative outcome such as awaiting advice. Conclusion This QI project led to an improvement in Rheumatology care provision locally. Engagement with support staff, education of clinical staff and implementation of clear standard operating procedures improved the utilisation of the Rheumatology APP resource. Results suggest that the APP role was effective locally in managing appropriately triaged patients, without a negative effect on patient care or other services. Continuing to improve utilisation will support management of the Rheumatology waiting list and improve patient care.
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Background/Aims Psoriatic arthritis (PsA) is a multi-system disease with a range of management options. Treatment may vary by geographic location. We compared disease characteristics and prescribing practices in the UK and Europe in the post-Covid era. Methods The ASSIST study was a cross-sectional observational study of PsA patients aged 18 years and older selected from 24 centres across 5 countries (UK, France, Germany, Italy and Spain) between July 2021 and March 2022 (IRAS: 287039). Patients attending a face-to-face appointment with a diagnosis of PsA made by a rheumatologist were selected by systematic sampling at each centre and treated in routine clinical practice. Patient and disease characteristics, current treatment and treatment decisions (medications unchanged, switched, added or reduced) were recorded. The analysis was descriptive, with no imputation of missing data. Results 503 patients were included, with arthritis subtype, patient age, disease activity and duration shown (Table 1). Physician- and patient-reported disease severity was highest in the UK, where median patient age was lowest. Conventional synthetic (cs) DMARDS constituted a higher percentage of current PsA treatment in UK than continental Europe (66.4% vs 44.9%), whereas biologic use was more frequent in Europe (68.1% vs 36.4%). Adalimumab was the most commonly used biologic in the UK and Spain. Adalimumab and secukinumab were equally used in Germany, and ixekizumab and adalimumab were joint-first in Italy. Implementing change to the current PsA treatment was most common in the UK, predominantly being a treatment increase. This may reflect the higher level of disease activity or younger patient age in the UK than other countries, as treatment escalation is more likely earlier in the disease course. In the UK, treatment escalation was more commonly achieved by medication addition (26.2%) than medication switch (14%) or dose increase (7.5%). In Europe, medication addition and switch were of more similar frequency (10.9% vs 9.85%). Conclusion Disease characteristics and treatment strategies varied between countries, but particularly between UK and the rest of Europe. In contrast to mainland Europe, csDMARDs predominated in the UK, perhaps reflecting current NICE guidelines. Treatment escalation was most common in the UK, in keeping with higher disease activity. (Table Presented).
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Objectives: Backgroud: Patients with immune-mediated inflammatory diseases (IMID), have an increased risk of presenting infections, this arises from immunosuppression related to the disease and its treatments. Vaccination in patients with autoimmune diseases is highly recommended by various clinical practice guidelines(1). Studies in Latin America show low rates of adherence, both in patients vaccine application and doctor's recommendations. One study shows that the lack of vaccination in 43% of their patients was due to their rheumatologist not recommending it (2). This is an eye opener on the key role physicians play in the overall outcome. Objective(s): To determine the adherence rate rheumatologists have, when it comes to recommending their patients vaccinations, suggested by clinical practice guidelines. Method(s): A descriptive study was performed, with previous authorization by the research department of the Colombian rheumatology association (ASOREUMA). A survey was sent via email to all its members asking about general knowledge about the subject and percentages on recommendations in their daily practice. Result(s): The survey was sent to 214 rheumatologist members of ASOREUMA, 34 (16%) of whom responded. In clinical practice there is a universal knowledge on the vaccination requirements for patients with IMID, nevertheless just 38.2% of clinicians tell patients to vaccinate against influenza of the 80%-100% of patients they see. For pneumococcus its 26.5%, hepatitis B 20.6%, human papilloma virus 8.8%, herpes zoster 2.9%. When it comes to SARS CoV2 vaccines it's by far the most recommended with 79.4%, and most physicians consider its mechanism of action before prescribing it. In table 1 we are summarizing the primary results. Conclusion(s): Despite the fact that rheumatologists are widely aware of the indications for vaccination in patients with IMID, these recommendations are not transmitted to all patients, due to the limited care time for each patient;in addition to the fact that the vast majority consider that the health system does not allow quick and timely access to these services.
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Background: Pulmonary Arterial Hypertension (PAH) is a form of pulmonary hypertension, where the narrowing of arteries in the lungs restricts blood flow and so increases pressure in the vessels. Studies have demonstrated that initial combination therapies are optimal for PAH management. However, prescription of monotherapy treatment is still prevalent as a first line therapy. Purpose(s): The purpose of this research was to investigate prescribing trends of physicians for first line patients with PAH in the UK, Germany, Italy and Spain. We investigated the proportions of newly diagnosed patients and the prescription trends for monotherapy and combination therapy prior to and during the COVID-19 pandemic. Method(s): A multi-country, multi-centre online medical chart review study of patients with PAH was conducted between April - June of 2019, 2020 and 2021 respectively. Recruited from a large access panel, 178 treating cardiologists, pulmonologists & rheumatologists in the UK (n=16), Germany (n=55), Italy (n=55) and Spain (n=52) were screened for duration of practice in their speciality and caseload (>=5 PAH patients in the last 3 months), and provided data on 694 PAH patients (UK = 71, Germany = 206, Italy = 208, Spain = 209). Reported patient data pertained to medical chart information reflecting the prior year, i.e., Q2 2021 data reflected the 2020 period (advent of the COVID-19 pandemic). Result(s): In this dataset, there has been a consistent decrease in the proportion of newly diagnosed (i.e. diagnosed within 12 months of being reported) patients reported from 2019 to 2020 and 2021. In 2019, 49% of the reported patients were diagnosed within the last 12 months. However, the newly diagnosed patient population dropped to 37% in 2020 and continued to drop to 27% in 2021. Despite this, there has been an increase in reported first line patients within the newly diagnosed segment from 74% in 2019, to 75% in 2020, then at 87% in 2021. This increase can be seen to coincide with the ongoing COVID-19 pandemic. In 2019, 58% of reported newly diagnosed patients were recorded as receiving monotherapy. This did drop to 33% in 2020;however, in 2021 monotherapy uptake increased to 47%. Of note, the usage of the endothelin receptor antagonist (ERA) drug class increased from 67% in 2019 to 83% in 2020 but dropped to 69% in 2021. Conclusion(s): This data set suggests a decreasing trend in newly diagnosed patients and a gradual shift in treatment type to first line monotherapy prescription, which coincided with the height of the COVID-19 pandemic. More newly diagnosed patients (those diagnosed within 12 months of being reported) are receiving monotherapy treatment at the expense of combination therapy, and this has also coincided with the pandemic. Further investigation using comparator cohort is warranted to assess whether the challenges physicians faced during the pandemic has had a causal effect on the prescribing habits for PAH therapies.
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Background. Myositis is a group of rare systemic disease and may be treated with immunosuppressives which increase the risk for poor outcome with the COVID19 pandemic. Patients with this condition may have higher rates of admission to the hospital. Methods. KP is a health insurance plan and provides care to about 800 thousand people (including Medicare and Medicaid population) in Maryland, District of Columbia and Northern Virginia. As part of quality improvements, we randomly looked at 40 patients from our larger cohort with myositis who are diagnosed and followed by a board-certified rheumatologist. We noted hospitalizations and Covid infection from March 1, 2020 to December 31, 2021. Results. Of the 40 patients, 29 (72%) were female and 11 were male. 19 (47%) were Blacks, 18 whites (including 6 Latino), and 3 Asians. Age ranged from 25 to 80 years with a mean age of 59.6 years. 25 (62%) patients had Dermatomyositis, 14 had polymyositis and 1 was IBM. The mean age at diagnosis was 55.9 years (range 23-80 years). 12 (30%) had myositis specific antibodies (4 Jo-1, 4 Mi-2, 1 PL 7, 1 PL 12, 1 PL7 plus PL12, 1 TIF Gamma). 22 (55%) were negative. Six did not have antibody testing. During this time, 11 (27.5%) were admitted to the hospital, 2 patients tested positive for COVID 19. One tested positive in the hospital and was asymptomatic. The other person was admitted for symptomatic COVID 19 infection. Other reasons for admission were cardiac, pulmonary (noncovid 19 related), infections, Gastrointestinal issues (including GI bleeding). One admission was for accidental bleach ingestion, and one for psychiatric admission. Of these 40 patients, 38 (95%) patients have received the COVID vaccinations, one patient refused, and for one person we do not have any record of vaccination. Conclusion. The admission rates to the hospital do appear to be higher for this group of patients with myositis, as is generally postulated. However, the reasons for admission were largely related to reasons other than COVID 19 infection and were related to general medical conditions.
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The Swedish Rheumatism Association, our umbrella Organization: In Sweden, there are approximately one million people with different rheumatic diseases, and about 1400 of them have a myositis diagnosis. In addition to several local associations, there are 3 nationwide diagnostic groups for systemic inflammatory diseases: Working group for systemic lupus erythematosus (SLE), Working group for Systemic Sclerosis and Working group for Myositis. Goals and vision: We form opinion and influence politicians and decision-makers at all levels in issues that are important to us, such as access to rapid care and opportunities for rehabilitation. Knowledge and Education: We educate: * Representatives who can share knowledge based on their own experience and to provide support and help for people living with rheumatic disease. * Volunteers for patient schools. * Patient Research Partners since 2008. Research and fundings: : * We are the single largest private funder of Swedish rheumatology research. * Patient Research Partners should become obvious members in research projects. Working group for Myositis was established in 2020 and most of our activities have been on-line. The number of members is growing as we spread out the information. We will continue with our on-line events and together with our experts arrange our first patient conference in 2022. We are a member of the Swedish Rare Disease Association and European Network ERN ReCONNET. We have now three Patient Research Partners with myositis and we will continue to participate in international research projects, such as IMACS, Rehabilitation & exercise SIG. Our mission is to give support to myositis patients and their families, share knowledge of their disease, facilitate meeting with others with the same diagnosis for an exchange of experiences or just for fun. Our goals are to: * Inform through newsletters, patient meetings, website and webcasts. * Arrange lectures by myositis experts. * Arrange annual patient conference. * Raise awareness for the disease in society and inform healthcare professionals within primary care units. * Contribute to that all patients receives equally good care all over the country. * Inform about research results, ongoing studies and update information on new treatments and drugs. * Contribute to that all newly diagnosed patients have access to patient education and written information material about myositis. * Contribute for opportunities for rehabilitation, such as training in warm water pools and access to rehabilitation facilities in warm climate. * Collaborate with the Youth organization of the Swedish Rheumatism Association for Juvenile Dermatomyositis and provide support for parents, children and adolescents. * Collaborate with the myositis organizations in other countries. Our Webinars: The experts who have shared their knowledge on our webinars are: Ingrid Lundberg, Professor;Maryam Dastmalchi, MD, Rheumatologist;Helene Alexanderson, PhD, Associate professor, PT;Malin Regardt, PhD, OT;Balsam Hanna, Specialist Rheumatology;Dag Leonard, MD, Rheumatologist;Antonella Notarnicola, MD, Rheumatologist;Fabricio Espinosa, Rheumatologist, PhD candidate;Kristofer Andreasson, PT, PhD candidate;Jonatan Sjogren, OT;Lars Nordelv, CBT Therapist, also a patient;Helena Andersson, MD, Rheumatologist;Hanna Brauner, PhD, Dermatologist. Among the topics our webinars have covered so far are: Diagnostic criteria of myositis, new research findings, existing treatments and ongoing studies, Physical activity and its effects on depression, safety of high-intensity interval training, Occupational therapy, Patient Reported Outcomes, Myositis Associated Antibodies and how to deal with anxiety, cardiac involvement and osteoporosis in myositis, clinical findings and treatments for Antisynthetase syndrome skin involvement in Dermatomyositis, Covid-19 and vaccination.
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Still's disease in children (systemic juvenile idiopathic arthritis - JIA) and adult Still's disease (ASD) are considered as systemic autoinflammatory diseases of unknown etiology, which are based on similar immunopathogenetic mechanisms associated with genetically determined disorders of the mechanisms of innate immunity. ASD was first described 50 years ago by the English rheumatologist Eric George Lapthorne Bywaters. The molecular basis of ASD immunopathogenesis is the activation of innate immunity associated with NLRP3 inflammasome-dependent mechanisms of inflammation, characterized by the overproduction of "pro-inflammatory" cytokines - interleukin (IL) 1 and IL-18, inducing the synthesis of other proinflammatory inflammatory mediators. A review of new data concerning the mechanisms of immunopathology, clinical polymorphism, laboratory biomarkers and the possibilities of ASD pharmacotherapy is presented. Particular attention is paid to the prospects for the use of monoclonal antibodies to IL-1beta - canakinumab. The problems associated with the generality of clinical and laboratory disorders, pathogenetic mechanisms and pharmacotherapy of ASD and coronavirus disease 2019 (COVID-19) are considered.Copyright © 2021 Authors. All rights reserved.
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Still's disease in children (systemic juvenile idiopathic arthritis - JIA) and adult Still's disease (ASD) are considered as systemic autoinflammatory diseases of unknown etiology, which are based on similar immunopathogenetic mechanisms associated with genetically determined disorders of the mechanisms of innate immunity. ASD was first described 50 years ago by the English rheumatologist Eric George Lapthorne Bywaters. The molecular basis of ASD immunopathogenesis is the activation of innate immunity associated with NLRP3 inflammasome-dependent mechanisms of inflammation, characterized by the overproduction of "pro-inflammatory" cytokines - interleukin (IL) 1 and IL-18, inducing the synthesis of other proinflammatory inflammatory mediators. A review of new data concerning the mechanisms of immunopathology, clinical polymorphism, laboratory biomarkers and the possibilities of ASD pharmacotherapy is presented. Particular attention is paid to the prospects for the use of monoclonal antibodies to IL-1beta - canakinumab. The problems associated with the generality of clinical and laboratory disorders, pathogenetic mechanisms and pharmacotherapy of ASD and coronavirus disease 2019 (COVID-19) are considered.Copyright © 2021 Authors. All rights reserved.
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The 2019 Coronavirus disease (COVID-19) vaccine is a major weapon in the fight against the severe acute respiratory syndrome brought about by coronavirus 2 (SARS-CoV-2). The vaccine significantly reduces the risk and severity of infection by SARS-CoV-2. Patients with systemic lupus erythematosus (SLE) need protection from vaccine-preventable diseases including COVID-19. SLE patients have higher rates of severe infections due to immunosuppressive therapies and multiple immunologic defects - both of which are capable of blunting the immune responses after vaccination. In the management of COVID-19, recommendations have been developed to guide adjustments and/or continuation of immunosuppressive therapies for an effective immune response following vaccination with mRNA-based or viral vector-delivered vaccines. Monoclonal antibodies have also become available since December 2021. Here we present three cases of SLE patients who contracted COVID-19 after vaccination. One was managed in ambulatory settings and two required inpatient hospital admission.Copyright © 2022
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Introduction: SARS-COV-2 pandemic challenged the medical education face-to-face meetings. ILD Virtual Clinics(ILD-VC) were thought as a non-traditional medical education model to address topics about a holistic managementof ILDs. Weekly videoconferencing interviews with local experts and Q&A from the public were developed. Objective(s): To describe a virtual medical education model with an innovative format through interviews with experts indifferent ILD topics as a best practice.Implementation: 20 episodes of ILD-VC were carried out with an audience of pulmonologists, rheumatologists andgeneral physicians from Argentina, Paraguay and Uruguay. Each 60 minutes duration episode with the presence ofthe coordinators and an expert in a specific topic for each episode recognized as an unmet need. The main objectivewas to discuss ILD management from different points of view and create a digital library with advices from thechosen experts. Some of the topics were: antigen searching for HP;determining progression in PF-ILDs;amongothers. The number of virtual assistants was 217 per episode (average) with a maximum of 382 and more de 4300connections in total. A third season in planned for 2022. Conclusion(s): This innovate format provided a better understanding of ILD holistic management. Disclosures: The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE). The authors did not receive payment related to the development of the abstract. Boehringer Ingelheim (BI) was given the opportunity to review the manuscript for medical and scientific accuracy as well as intellectual property considerations. The study was supported and funded by BI.
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Background: Patients with Immune Mediated Inflammatory Diseases (IMIDs) treated with immunosuppressive drugs are at an increased risk of infections and a more complicated course of the infection, including vaccine-preventable infections. National and international guidelines have specified vaccination strategies in patients with IMIDs. However, the adherence to these guidelines in clinical practice is uncertain. Therefore, we evaluated the current vaccination status of patients with IMIDs at the outpatient clinic of the Erasmus MC Rotterdam. Method(s): Between August 2022 and October 2022, a survey was sent out to patients with various IMIDs at the rheumatology, dermatology and gastroenterology outpatient clinics. Only patients on immunosuppressive treatment were included. The survey contained questions on patient demographics, disease characteristics and current vaccination status. Result(s): The survey was sent out to 3,345 patients with IMIDs, of whom 1,094 patients filled in the questionnaire (response rate 32.7%). Mean age was 51 +/- 16 years and 40.8% were male (Table 1). Patients were treated by a dermatologist (n=306), gastroenterologist (n=414) and/or rheumatologist (n=527). Overall, 55.1% of patients received a yearly influenza vaccination and 9.2% occasionally (Table 2). Furthermore, 8.7% of patients received the pneumococcal vaccination five-yearly and 1.4% occasionally. Both the influenza and pneumococcal vaccination rates were highest in patients with rheumatoid arthritis (64.1%, and 14.7%, respectively). On the contrary, patients with hidradenitis suppurativa had the lowest rates for both the influenza vaccination (32.3%) and pneumococcal vaccination (n=0). Overall, 91.7% of patients (n=1,003) received one or more COVID-19 vaccinations. Conclusion(s): Patients with Immune Mediated Inflammatory Diseases are insufficiently protected against vaccine-preventable infections due to low vaccination rates. Better implementation strategies of current guidelines on seasonal influenza vaccination and pneumococcal vaccination are required. A high rate of COVID-19 vaccination was observed, possibly indicating the willingness of patients to receive vaccinations. Further research into facilitators and barriers to vaccination in these specific patient populations is required.
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Objectives: To investigate the risk of flare-ups after COVID-19 vaccination in patients with rheumatic disease. Method(s): A total of 1,617 patients with rheumatic diseases were identified from three rheumatology clinics. Patients were interviewed for demographic data, disease activity, and vaccination status. Disease flare-up was determined clinically by independent rheumatologists. Change of serum markers and medications were retrieved from medical records. The risk of exacerbation of rheumatic disease, change in serum markers, and escalation of rheumatic medications between vaccinated and nonvaccinated patients were determined using Cox, linear, and logistic regression models, respectively. Possible confounding factors were also taken into consideration. Result(s): Among 562 (34.76%) patients who received COVID-19 vaccination, rheumatic disease (HR = 2.10, P < 0.001), inflammatory arthritis (HR = 2.71, P < 0.001), rheumatoid arthritis (RA) (HR = 2.03, P = 0.002), spondyloarthritis (SpA) (HR = 4.78, P < 0.001), autoimmune disease (HR = 1.77, P = 0.01), and systemic lupus erythematosus (SLE) (HR = 1.99, P = 0.02) were associated with postvaccination clinical flare-up. Adult Still's disease (B = 12.76, P = 0.03) was associated with increased serum C-reactive protein (CRP). No association was found between vaccination and escalation of rheumatic medication. Subgroup analyses showed that only the mRNA vaccine was associated with flare-ups. Conclusion(s): COVID-19 vaccination was associated with minor disease flare-up but not escalation of rheumatic medications. In the absence of absolute contraindications, COVID-19 vaccination is recommended in patients with rheumatic disease. KEY MESSAGES 1. Vaccination is effective in the prevention of morbidity due to COVID-19 in patients with autoimmune diseases. 2. The mRNA vaccine was associated with mild rheumatic disease flare-up. 3. Inactivated virus vaccine is preferable to mRNA vaccine in patients with active autoimmune disease. Copyright © 2023 The Author(s).
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Objectives: To investigate the risk of flare-ups after COVID-19 vaccination in patients with rheumatic disease. Method(s): A total of 1617 patients with rheumatic diseases were identified from three rheumatology clinics. Patients were interviewed for demographic data, disease activity, and vaccination status. Clinical disease flare up was determined independently by expert opinion by managing rheumatologists. Change of serum markers and medications were retrieved from medical records. The risk of exacerbation of rheumatic disease, change in serum markers, and escalation of rheumatic medications between vaccinated and non-vaccinated patients were determined using cox, linear and logistic regression models respectively. Possible confounding factors were also taken into consideration. Result(s): There were 562 (34.76%) patients received COVID-19 vaccine. After vaccination, rheumatic disease (HR = 2.10, P < 0.001), inflammatory arthritis (HR = 2.71, P < 0.001), rheumatoid arthritis (RA) (HR = 2.03, P = 0.002), spondyloarthritis (SpA) (HR = 4.78, P < 0.001), autoimmune disease (HR = 1.77, P = 0.01), and systemic lupus erythematosus (SLE) (HR = 1.99, P = 0.02) were associated with clinical flare up. Adult still's disease (B = 12.76, P = 0.03) was associated with an increase in CRP level. Escalation of rheumatic medications were not associated with COVID-19 vaccination in all diseases. Subgroup analyses showed only mRNA vaccine was associated with disease flare ups. Conclusion(s): COVID-19 vaccine was associated with minor disease flare up but not escalation of rheumatic medications. In the absence of absolute contraindications, full COVID-19 vaccination in patients with rheumatic disease should be encouraged by managing rheumatologists.
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Background/Purpose: Covid-19 vaccine is one of the most effective strategies to control coronavirus disease 2019 (COVID-19) pandemic. However, safety data of these vaccines among patients with autoimmune diseases is limited. We report case series of patients who developed new-onset or flares of autoimmune disease after COVID-19 vaccination. Method(s): We conducted a retrospective chart review of patients treated by rheumatologists for new-onset or flares of autoimmune diseases after COVID-19 vaccination between March 2021-July 2022. Patients who had COVID-19 infection or other explainable causes were excluded. According to World Health Organization's Adverse Event Following Immunization causality assessment, we use 30-day cut off. Patients were divided into 2 groups. The first group had symptom onset within 30 days after vaccination whereas the second group had symptom onset 31-90 days post-vaccination. Patient's demographics, clinical manifestations and laboratory data were collected. Result(s): We identified 18 (46%) patients with new-onset autoimmune diseases, and 21 (54%) patients with autoimmune disease flares after COVID-19 vaccination. Four patients had recurrent flares following subsequent vaccination. The median age was 45 years and 66.7% were females. The median duration from last vaccination to symptom onset was 16 days. Twenty-two (56.4%) of patients developed symptoms within 30 days post-vaccination. Symptoms occurred mostly after the 2nd (44.2%) dose. The most common diagnosis was systemic lupus erythematosus (SLE) (32.6%) with modified Systemic Lupus Erythematosus Disease Activity Index-2000 ranging from 1-21 at diagnosis. Among patients with disease flares, 4 patients had undiagnosed autoimmune diseases before vaccination, 4 patients stopped immunosuppressive medications months prior to disease flares, 5 patients stopped immunosuppressive medications 1 week after vaccination, and 7 patients continued immunosuppressive medications. Fourteen (35.8%) cases required hospitalization, four of which were treated in intensive care units. The remaining patients were treated at outpatient clinic. Seven patients required initiation or adjustment of biologic disease modifying anti-rheumatic drugs, 19 patients received intravenous cyclophosphamide and/or intravenous methylprednisolone, 3 patients received intravenous immunoglobulin, and 5 patients underwent plasmapheresis. One patient improved without intervention. Three (7.9%) patients with new-onset autoimmune diseases died: 2 patients with SLE, and 1 patient with Hemophagocytic lymphohistiocytosis. Conclusion(s): There are cases of patients with new-onset or flare of autoimmune diseases occurring after COVID-19 vaccination. Although previously undiagnosed autoimmune disease or prior discontinuation of immunosuppressive medications partly contributed to disease flares, some cases occurred without other precipitating factors and were severe. Disease awareness and early detection are needed to improve patient outcomes. (Figure Presented).
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Background: Telemedicine became the emergent means of providing and continuing medical care due to the COVID 19 pandemic. This study aims to evaluate the knowledge, perception, and satisfaction with the use of telemedicine among patients with rheumatic diseases. An understanding of our patients' experiences can be utilized to provide access to care, improve gaps in delivery of care, and improve healthcare disparities. Method(s): Filipino patients with rheumatic disease who had telehealth visits between June 2020 and August 2021 in St Luke's Medical Center Outpatient Department participated in an online survey. Information on demographics, diagnosis, knowledge and experience on telemedicine, and perspectives on benefits and limitations of telemedicine were collected. Result(s): There were 70 respondents: 52.9% with SLE, 25.7% with RA, 10% with osteoarthritis, 5.7% with psoriatic arthritis, 2.9% with scleroderma. Results showed that 64.3% are familiar with the use of video conference platforms. Facebook messenger was the most used (85.7%). Half of respondents have used telemedicine on their own, while 33% required assistance. The remaining respondents have not used telemedicine due to lack of experience or awareness on how to proceed with consults. The reasons for using telemedicine were restrictions of the pandemic (82.9%), limited access to clinics (31.4%), and disability (1.4%). Most remain satisfied with telemedicine (75.7%), 50% of patients stated that telemedicine was comparable to an in-clinic visit, and 85.7% (N = 60) would recommend its use. Conclusion(s): Filipinos with rheumatic disease are knowledgeable on online platforms and telemedicine, however, it is important to note the digital divide. Patients need assistance and improved awareness on accessing remote care. Providing continuity of healthcare can lead to less complications and better outcomes despite pandemic restrictions. There is an overall favorable satisfaction for care. Half the respondents remain satisfied with telemedicine. Rheumatologists need further studies on benefits and outcomes on providing remote healthcare.
ABSTRACT
Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.
ABSTRACT
Introduction/Background: Primary bone marrow oedema syndrome is an elusive and less well-defined entity. Whether Rheumatologists should consider it as a stand alone diagnosis, is debatable. It possibly would be best described as an MRI feature which could be a finding in a number of diseases which would include the initial phases of Osteonecrosis of the bone, Rheumatoid Arthritis, Spondyloarthritis, Enthesitis related, Post traumatic, OA, Infections and Cancers. The treatment options become constricted due to the paucity of evidence. Rheumatologists need to consider this as an area of unmet need with development of consensus classification criteria and treatment approaches. Description/Method: 27-year-old male, Height 174 cms Weight 90 Kgs BMI 29 Kg/m2, became symptomatic in Jan 2022 with complains of pain in the both hip joints & groin regions, pain became excruciating and he became bed-bound, with early morning stiffness lasting approximately 45 mins. Had received steroids for COVID infection in August 2020. Investigations Hb 13.5gm/dl TLC 7000/mm3 Platelet 400 x 103/mm3 Sr Bil 0.8mg/dl AST 16 IU/L. ALT 24 IU/L Sr Creatininine 1.1mg/dl Blood Sugar Levels, Fasting 89 mg/dl Post Prandial 102 mg/dl ESR 10mm in 1st hour by Wintrobes method CRP Quantitative 29.38mg/L HLA B27 by PCR Negative, RF Negative, ACCP Negative Serum, IgG, Beta2 Glycoprotein 1.44 SGU Serum, IgM, Beta2 Glycoprotein 3.44 SGU Serum, IgG, Cardiolipin antibody 8.4 GPL Serum, IgG, Cardiolipin antibody 17.45 GPL Lupus anticoagulant by DRVVT Negative Sr Cholesterol 211mg/dl HDL 29 mg/dl LDL 156mg/dl TGs 130 mg/dl MRI Hips & SI joints Transient bone marrow oedema/osteopenia of bilateral hip. PET CT Increased metabolic activity in both hip joints Bone Scan (99mTcMDP) Increased vascularity in perfusion phase, increased accumulation in soft tissue in blood pool phase and increased uptake in bilateral Hip joints in skeletal phase scan, suggestive of CRPS Type-I. Management Was initially managed with Tab Etoricoxib 90mg BD, also started on Tab Sulphaslazine and Tab Methotrexate. However, when he had no symptomatic relief he was administered Inj Infliximab on 12 May 2022 and a second dose on 9 June 2022. He had excellent pain relief after the 1st dose, however after 10 days of the administration, he again began experiencing pain especially after walking. He also had pain in the knees on this occasion. He was also administered Inj Zoledronic 4mg on 23 May 2022. He is at present not requiring any NSAIDs over the last 1 month. Discussion/Results: The patient having presented with excruciating and debilitating pain was worked up and evaluation revealed features of bone marrow oedema on MRI which was corroborated with bone scan and PET CT imaging. The acute phase reactant CRP was also significantly elevated. The patient also gave history of early morning stiffness lasting approximately 45 mins. Hence an underlying Inflammatory process such as Spondyloarthritis(Peripheral) with enthesitis was considered. The confounding factors were the pain which worsened on mobilization, HLA B27 negative status, Rheumatoid Factor and ACCP negative status and past history of having received IV Corticosteroids for COVID infection in August 2020. In view of the debilitating pain and aworking diagnosis of Spondyloarthritis, hewas started onNSAIDs alongwith rest, initially, followed by conventional synthetic disease modifying agents in Rheumatic disease followed by biologic synthetic diseasemodifying agent - Inj Infliximab. The thought process was to avoid prolonged NSAID use to prevent the associated side effects. However, since Avascular Necrosis of the Femoral head is a very likely possibility, the patient is planned to be kept under close follow up. Key learning points/Conclusion: Collaborative efforts between the Departments of Nuclear Medicine, Radiology, Orthopaedics and Rheumatology are crucial in the early detection and approach to cases of Bone Marrow oedema. Avascular necrosis of head of Femur is a far more common entity and must be kept in ind even when a diagnosis of Bone Marrow oedema syndrome is being entertained. Diagnosis of Bone Marrow oedema syndrome must be entertained only as a diagnosis of exclusion. Continued follow up and regular imaging must be pursued rigorously in patients diagnosed with Bone Marrow oedema syndromes. There is a requirement to document acute phase reactants such as CRP and ESR in patients diagnosed with Avascular necrosis of bone as this data could help us differentiate AVN from Primary Bone marrow oedema in the early stages.
ABSTRACT
Background: The emergence of the coronavirus disease (COVID-19) prompted pharmaceutical companies to develop effective vaccines to address the problem. While studies prove the vaccines are safe, rare systemic side effects remain possible. All types can cause various vaccine-related adverse reactions which are continuously being monitored. This paper aims to highlight new data on immunologic reactions to COVID-19 vaccines. Morphea demonstrated after COVID-19 vaccination is rare. Herein, we report a case of morphea that was most likely triggered by the immune response against inactivated COVID-19 vaccine. Method(s): A case of morphea was reviewed at the clinic in a tertiary hospital in the Philippines. Result(s): A 48 year old Japanese male had no underlying co-morbidities and no previous COVID-19 infection. He had his first dose of inactivated COVID-19 vaccine, coronaVac (sinovac) with no untoward reactions. After a month, he had his second dose. One week later, the patient started to have a red plaque on his upper back, palpable, tender on palpation and pruritic. Review of systems was unremarkable. The patient denied any insect bites or skin trauma. No medications applied or taken. No known allergies to food, medications or vaccines. He is a 32 pack years smoker. No family history of any autoimmune diseases. In five months, the skin lesion insidiously progressed, thickened and now spreading to the left side of the back. The patient sought consult with a dermatologist and rheumatologist. Physical examination revealed thickened skin and subcutaneous tissue on the upper back with post-inflammatory hyperpigmentation. Work-up showed normal complete blood count, normal chest x-ray, non-reactive Hepatitis B antigen. Antinuclear antibody (ANA) was positive with 1:80 titer and nuclear speckled pattern. Anti-double stranded DNA (anti-dsDNA), anti-smith, antinuclear ribonucleoprotein (anti-RNP), anti-SSA, anti-SSB and anti-Jo- 1 were all negative. The patient's skin biopsy to the reticular dermis showed findings that are consistent with Morphea. The patient was then started on Methotrexate. Conclusion(s): People should be educated about the possible outcomes of COVID-19 vaccines. One of these are immune-related diseases, such as morphea. The underlying mechanism of morphea is multifactorial but one hypothesis highlighted that the spike glycoprotein from vaccination drives these skin reactions. Other studies demonstrated molecular mimicry to viral epitopes. Discussing this cutaneous manifestation secondary to COVID-19 vaccine stressed the importance of this clinical condition, in order to provide a proper diagnosis and therapeutic management. Although there are novel case reports of morphea induced by COVID-19 mRNA vaccine, inactivated COVID-19 vaccine-related morphea has not been reported yet.